4708 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


GIFT  OF 

SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


THE  HISTORY  AND  TECHNIQUE 


OF    THE 


VAGINAL  RADICAL  OPERATION 


BY 

PROF.  DR.  LEOPOLD  LANDAU  AND  DR.  THEODOR  LANDAU, 

OF    BERLIN. 


Snglisb  translation  b£ 
B.  L.  EASTMAN,  M.D., 

ASSISTANT  IN  THE  LANDAU  FRAUEN-KLINIK,  BERLIN  ;   EX-INTERNE,  COUNTY 
HOSPITAL,  CHICAGO;  FSLLOW  OF  THE  BRITISH  GYN/ECOLOGICAL  SOCIETY, 

AND 

ARTHUR   E.  GILES,  M.D., 

B.Sc.  LOND.,  M.R.C.P.  LON-D.,  F.R.C.S.  ED., 

ASSISTANT-SURGEON,    CHELSEA    HOSPITAL    FOR    WOMEN,    LONDON. 


NEW  YORK : 
WILLIAM     WOOD    &    COMPANY. 

1897. 


BitmttaU 

library 

IOP 
1*0 


PREFACE 

TO   THE   GERMAN    EDITION. 


TO-DAY  the  knife  is  the  emblem  of  gynaecological  treatment ; 
it  has  supplanted  the  aromatic  fomentation,  mercurial  inunc- 
tion, and  the  painting  of  the  long-suffering  portio,  which 
ruled  the  therapy  of  diseases  of  women  until  within  a  few 
decennia.  Simultaneously  with  the  invention  of  the  various 
operations,  the  field  of  indications  for  them  was  widened 
indefinitely.  Several  years  ago  Noeggerath  gathered  up  a 
long  and  melancholy  list  of  diseases  in  which  Emmet's 
operation  was  indicated.  Trachelorrhaphy  was  the  curative 
remedy  for  the  following  conditions,  to  mention  but  a  few 
^put  of  the  twenty-six :  Prolapse  of  the  uterus  and  vagina, 
>retroversion  and  flexion  of  the  uterus,  epilepsy,  dementia, 
N^and  salivation.  At  least  the  published  reports  stated  so. 
was  it  any  different  with  the  indications  for  castration 
amputation  of  the  cervix  ? 

The  success  of  these  operations  for  the  given  indications 
NJwas  proved  by  the  authors  by  means  of  imposing  lists  of 
patients  who,  under  the  protection  of  asepsis  and  the  toler- 
V\ance  of  the  female  genitalia,  had  escaped  with  their  lives. 
^VThe   '  scientific '    basis   for   the  real  value  of  an  operation 
; ^developed  pari  passit  with  the  operative  lust,  until  it  reached 
the  simple  formula : — Mortality  of  the  operation  in  100-200 
cases  —  o;  therefore  it  is  not  a  dangerous  operation,  and 
hence  it  must  be  good.     The  permanent  success,  permanent 
cure,  the  only  real  standard  of  the  worth  of  the  operation, 
^  underwent  complete  atrophy  during  this  '  rage  for  numbers.' 
^     Often  enough  the  suggestive  effect  of  an  operation  did  not 
"\;last  as  long  with  the  patient  as  did  the  auto-suggestion  upon 
\)  the  inventor  of  the  operation  ;  and  just  as  with  the  '  malade 

i 

624348 


PREFACE  TO  THE  GERMAN  EDITION 


imaginaire  '  of  an  earlier  time,  the  '  medecin  imaginaire  '  of 
to-day  also  needs  his  Moliere.  Thus,  it  is  not  surprising  that 
one  operation  '  having  the  most  excellent  results '  is  shortly 
replaced  by  another  '  still  more  effective,'  and  that  each 
operation  is  alarmingly  short-lived. 

Is  it  any  wonder  that  the  practitioner,  after  trying  in  vain 
to  keep  pace  with  the  changing  play  of  the  operation-in- 
ventor, the  over-hasty  varieties,  combinations  and  confusion 
of  the  operations  and  indications,  finally  becomes  discouraged 
by  the  mass  of  argument  and  contradiction,  and  turns  his 
back  on  all  operative  measures  ?  Then  he  necessarily  goes 
to  the  other  modern  extreme,  and  becomes  a  therapeutic 
nihilist.  Certainly,  such  a  therapy  is  more  in  accord  with 
the  real  duties  of  the  thoughtful  physician  than  is  the  opera- 
tive furore  of  some  of  our  enthusiastic  technicians. 

What  is  the  practitioner  to  think  of  the  gynaecologist  who, 
for  instance,  makes  the  uncomplicated  displacement  of  the 
womb  an  excuse  for  dangerous  operative  measures  ?  On  the 
other  hand,  it  is  hardly  necessary  to  point  out  how  false  it 
were  to  go  to  extremes  in  the  other  direction,  and  strike  out 
all  operative  manipulation  from  the  field  of  gynaecology. 

The  justification  of  any  surgical  measure  must  depend  on 
its  fulfilling  two  conditions  :  first,  that  the  disease  in  question 
is  not  capable  of  cure  by  a  simpler  means,  nor  of  spontaneous 
cure.  Second,  that  the  patient  can  be  thoroughly  and  per- 
manently relieved  of  his  suffering  by  the  proposed  operation. 
If  both  conditions  can  be  fulfilled,  the  operation  is  thus 
legitimatized,  and  in  fact,  in  a  surgical  sense,  forms  the  specific 
therapy  for  this  particular  disease. 

We  regard  the  hystero-salpingo-oophorectomy,  which  we 
call  the  vaginal  radical  operation,  as  such  an  operation.  This 
is  what  we  make  use  of  in  the  treatment  of  double  inflam- 
matory or  suppurative  diseases  of  the  tubes  and  ovaries,  a 
class  of  cases  which  resists  every  other  method  of  treatment. 

This  advocacy  of,  and  enthusiasm  for,  such  a  radical  and 
severe  operation  may  seem  strange  as  coming  from  us,  since 
in  speech  and  writing  we  have  so  continuously  warned  against 
operative  meddlesomeness,  against  intra-uterine  injection, 
castration  of  neurotics,  cervix  amputation,  and  ventro-  and 
vagino-fixation  of  the  uterus.  Compared  with  the  radical 


PREFACE  TO  THE  GERMAN  EDITION  iii 

extirpation  of  the  entire  internal  genitalia,  does  not  the 
removal  of  the  adnexa  by  the  less  dangerous  (?)  cceliotomy 
represent  an  easier  and  more  effective  method  ?  No,  neither 
easier  nor  more  effective. 

The  mere  removal  of  both  inflamed  or  suppurating  ap- 
pendages, whether  through  the  vagina  or  through  the  belly, 
with  separation  of  adhesions  to  the  intestines,  or  even  with 
the  introduction  of  oil  into  the  peritoneal  cavity,  may  give 
good  immediate  results,  but  the  permanent  cure  does  not 
follow.  The  women  recover  from  the  operation,  but  not 
from  their  disease,  because  only  one  portion  of  the  diseased 
structures  is  removed,  while  the  real  source  and  origin  of  the 
affection,  the  diseased  uterus,  is  left  behind  to  light  up  the 
old  trouble  again  at  any  time. 

Such  experiences,  which  we  also  have  had  after  the  simple 
removal  of  tubes  and  ovaries,  have  robbed  these  partial, 
really  incomplete  operations  of  their  hold,  for  us  at  least, 
and  have  demonstrated  that  it  is  better,  for  the  patient,  to 
complete  the  work  in  hand  instead  of  doing  it  piecemeal. 
In  fact,  it  is  better  in  such  cases  not  to  operate  at  all  than  to 
do  so  but  imperfectly. 

The  words  of  the  ancient  poet  are  strikingly  appropriate 

here : 

'  Curando  fieri  quaedam  majora  videmus 
Vulnera,  quas  melius  non  tetigisse  foret.' 

It  is  exactly  the  permanent  results  achieved  by  the  vaginal 
radical  operation  in  the  disease  of  the  adnexa  which  de 
monstrate  its  superior  value  over  the  mere  salpingo- 
oophorectomy. 

It  is  well  known  that  the  immediate  results  of  this  opera- 
tion are  also  good.  In  the  past  few  years  we  have  had  many 
opportunities  of  reporting  from  time  to  time  the  cases 
operated  on  by  this  method,  and  particularly  the  results 
attained  in  the  treatment  of  complicated  pelvic  abscesses. 

This  book  is  written  in  response  to  the  gratifying  interest 
which  the  profession  has  shown  in  these  methods,  and  in 
deference  to  those  attending  the  operations  in  our  clinic  who 
have  so  often  expressed  the  desire  to  have  an  accurate 
description  of  our  operative  technique.  The  work,  describing 
as  it  does  the  methods  which  we  practise  for  the  vaginal 

i — 2 


iv  PREFACE  TO  THE  GERMAN  EDITION 

extirpation  of  the  internal  genitalia,  is  intended  as  a  text-book 
of  this  operation. 

In  following  out  this  didactic  purpose,  we  have  had  to 
dispense  with  a  short  continuous  description  of  the  method. 
We  have  explained  in  a  general  way,  first,  the  ground  prin- 
ciples of  our  technique,  and  then,  in  a  second  part,  we  have 
described  each  individual  method  in  detail,  with  special 
reference  to  its  indications.  Each  procedure  is  explained 
individually,  and  in  this  way  the  work  is  intended  as  a  book 
of  reference  for  the  surgeon.  Naturally,  certain  repetitions 
are  unavoidable — in  fact,  necessary. 

Further,  we  hope  that  the  illustrations  embodied  in  the 
text  will  add  to  its  instructive  value,  and  represent  more 
clearly  the  different  stages,  varieties,  and  subvarieties  of  the 
operation. 

We  have  partly  employed  a  diagrammatic  form  of  illustra- 
tion, but  many  of  the  plates  represent  photographs  taken 
during  the  different  steps  of  the  operation. 

In  order  to  dispose  of  the  criticism  that  our  classification 
was  only  theoretical,  a  number  of  specimens  acquired  by  the 
various  methods  have  been  put  together  again,  and  pho- 
tographed from  nature.  They  are  intended  to  explain  the 
indication  for,  and  the  description  of,  the  corresponding 
method,  to  prove  that  it  is  really  practical,  and  to  enliven 
the  theoretical  discussion.  For  the  same  reason  we  have 
added  clinical  and  pathological  data  concerning  each  spe- 
cimen so  illustrated. 

In  arranging  the  specimens,  as  well  as  in  the  preparation  of 
the  work  itself,  we  were  especially  aided  by  our  assistant, 
Dr.  Ludwig  Pick. 

As  a  prelude  to  the  technique  of  the  operation,  we  have 
given  an  outline  of  its  history.  In  this  we  were  actuated  by 
the  view  that  the  development  of  the  operation  itself  affords 
a  series  of  illustrations  of  its  aims  and  advantages.  In  this 
sense,  therefore,  the  historical  survey  may  be  considered  as 
a  part  of  the  general  technique  of  the  operation. 

LEOPOLD  AND  THEODOR  LANDAU. 

BERLIN. 


PREFACE 

TO   THE   ENGLISH    EDITION. 


IN  bringing  this  work  before  the  English-speaking  members 
of  the  profession,  we  have  been  actuated  by  the  knowledge 
that  no  such  detailed  and  complete  description  of  the  vaginal 
operation  has  as  yet  appeared  in  our  language.  In  this  we 
have  received  the  support  and  encouragement  of  English 
and  American  doctors  attending  the  lectures  and  operations 
at  the  Landau  clinic. 

There  is  no  question  but  that  the  total  extirpation  of  the 
internal  sexual  organs  for  tubal  and  pelvic  suppuration  is  a 
radical  procedure.  It  is  radical,  and  it  is  just  this  quality 
which  makes  the  operation  peculiar  to  itself,  and  gives  it  its 
intrinsic  value  in  the  treatment  of  these  diseases.  After  all, 
pus  and  granulation  tissue  in  the  female  pelvis  are  not  so 
greatly  different  from  like  products  when  existing  in  other 
cavities  of  the  body,  and  when  their  removal  is  demanded, 
why  should  not  as  vigorous  measures  be  employed  here  as 
elsewhere  ?  Those  who  follow  the  literature  and  attend  the 
discussions  pertaining  to  cases  of  this  class  must  be  con- 
vinced that  there  is  everywhere  a  striving  for  more  thorough 
and  complete  work  in  this  line,  as  evidenced  by  the  attention 
paid  to  ligature  material,  stump  exudates,  toilet  of  the  peri- 
toneum, and  the  ever-recurring  question  of  drainage.  The 
drift  is  more  and  more  toward  radicalism,  and  the  question 
at  present  is  not  why,  but  how.  Hardly  anyone  denies  the 
desirability,  or,  indeed,  necessity,  of  radical  measures,  but 
the  technique  has  been  the  stumbling-block  and  the  barrier 
hitherto. 


vi  PREFACE  TO  THE  ENGLISH  EDITION 

And  herein  is  exactly  the  value  of  the  Landaus'  work — the 
great  simplicity  and  yet  completeness  of  the  technique  which 
they  have  developed  and  practised,  and  lately  described  in 
detail. 

This  is  not  the  place  for  statistics,  hence  it  will  suffice  to 
say  that  the  mortality  of  the  vaginal  total  extirpation  is  less 
than  that  of  abdominal  salpingectomy.  The  permanent 
results  are  incomparably  better.  What  more  is  necessary  ? 

The  desire  to  place  the  technique  before  the  profession  in 
a  readable  and  connected  form  is  the  origin  of  the  German 
as  well  as  of  the  English  edition.  We  can  only  hope  that 
in  its  new  form  it  will  meet  with  the  same  favour  as  the 
original  has. 

Our  sincere  thanks  are  due  to  Professor  Landau  for  his 
many  kindnesses  during  this  work,  and  during  the  whole 
service  of  one  of  us  in  his  clinic ;  also  to  Dr.  Theodor 
Landau  for  the  literature  which  he  has  placed  at  our  disposal, 
and  for  his  personal  aid  in  the  translation. 

B.  L.  EASTMAN,  BERLIN. 
ARTHUR  E.  GILES,  LONDON. 
May,  1897. 


CONTENTS. 


PART   I. 

THE  DEVELOPMENT  OF  THE  VAGINAL  RADICAL 
OPERATION. 

CHAPTER  PAGE 

I.    HISTORY  OF  REMOVAL  OF   THE   UTERUS    UP   TO   THE   TIME 

OF   PEAN  -         II 

ii.  PEAK'S  IMPROVEMENTS — PEAN'S  OPERATION  -       16 

III.  THE  FURTHER  ADOPTION  OF  PEAN's  OPERATION — ITS  IN- 
DISCRIMINATE USE — DEVELOPMENT  OF  THE  VAGINAL 
RADICAL  OPERATION  -  19 

IV.    THE     VAGINAL     RADICAL     OPERATION  :      ITS     DEFINITION, 
LIMITS,    INDICATIONS,    AND    ADVANTAGES — THE   PRIN- 
CIPLES  AND   TECHNICAL   AIDS   OF   OUR   OPERATION      -         22 
V.    THE   VAGINAL   RADICAL   OPERATION   IN   A   BROADER  SENSE         32 

PART    II. 

TECHNIQUE  OF  THE  VAGINAL  RADICAL  OPERATION. 

A.— GENERAL  CONSIDERATIONS. 

I.  OUR    OPERATION  :    THE    ENUCLEATING    PROCEDURE — THE 

SO-CALLED    CLAMP   METHOD — QUALITIES   AND   ADVAN- 
TAGES   OF   THE    CLAMPS  -         35 
II.    NON-CLOSURE    OF    THE    ABDOMINAL    CAVITY — MECHANISM 

OF    THE    HEALING  -         40 

III.  MORCELLEMENT  -         45 

IV.  CLASSIFICATION,   MECHANISM   AND    METHOD  OF   PERFORM- 

ANCE  OF   THE   MORCELLATING   OPERATIONS     •  -         46 

V.    MORCELLEMENT    AND    HEMOSTASIS  -          51 

VI.  OUR  CLASSIFICATION  OF  THE  VAGINAL  RADICAL  OPERA- 
TION ACCORDING  TO  ITS  USES  —  THE  INDICATIONS 
BASED  UPON  TOPOGRAPHICAL  ANATOMY  -  53 

B.— SPECIAL  TECHNIQUE. 

I.    PREPARATION    OF    THE    PATIENT THE    ANESTHETIC,    THE 

ASSISTANTS,    ETC.  -  -         55 

II.  ARMAMENTARIUM  :    INSTRUMENTS    AND   DRESSINGS  -          60 


CONTENTS 


CHAPTER  PAGE 

III.  TECHNIQUE  OF  THE  VARIOUS  FORMS  OF  THE  OPERATION — 

REMOVAL  OF  THE  APPENDAGES  AND  MOBILE  UTERUS 
WITHOUT  MORCELLEMENT  -  68 

FIRST  STAGE  :  EXPOSING  AND  FIXING  THE  PORTIO       68 

SECOND  STAGE  :  CIRCULAR  INCISION  OF  THE  PORTIO 

— VARIOUS  INCISIONS — EXPLORATORY  INCISION  7  I 

THIRD  STAGE  :  FREEING  THE  UTERUS  FROM  THE 
PERICERVICAL  TISSUE — THE  ANATOMICAL  RE- 
LATIONS OF  THE  BLADDER  AND  URETERS  TO 
THE  GENITAL  ORGANS  -  77 

FOURTH  STAGE  :  OPENING  THE  PERITONEAL  CAVITY       86 

FIFTH  STAGE  :  LUXATION  OF  THE  UTERUS  AND 

ADNEXA  INTO  THE  VAGINA  -  -  88 

SIXTH  STAGE  :  H^EMOSTASIS  AND  EXCISION — THE 
NUMBER  OF  CLAMPS  AND  METHOD  OF  THEIR 
APPLICATION  -  -  93 

SEVENTH  STAGE  :  REVISION  OF  THE  WOUND — 
INTRODUCTION  OF  THE  GAUZE — PROCEDURE 
IN  CASE  OF  A  TOO  LARGE  OR  TOO  SMALL  OPEN- 
ING IN  THE  VAGINAL  VAULT  -  -  104 

IV.  REMOVAL  OF  THE  ADNEXA  AND  ADHERENT  UTERUS  WITH- 

OUT MORCELLATION  -  -     112 

V.  REMOVAL  OF  THE  UTERUS  AND  APPENDAGES  WITH  THE 
AID  OF  MORCELLEMENT — SPLITTING  THE  UTERUS — 
MEDIAN  SECTION  OF  ONE  WALL  -  121 

VI.  COMPLETE  MEDIAN  SECTION  OF  THE  UTERUS      -  -     128 

VII.  MORCELLATING  OPERATIONS  (TRUE  MORCELLEMENT)        -     135 
VIII.  BILATERAL  SECTION  OF  THE  UTERUS,  AND  TRANSVERSE 
EXCISION     UNDER     PRIMARY    H^EMOSTASIS     (PEAN'S 
CLASSICAL  MORCELLEMENT)    -  -     144 

IX.  IRREGULAR  MORCELLATION  (TRUE  MORCELLEMENT)         -     150 
X.  THE  DIFFERENT  FORMS  OF  IRREGULAR  MORCELLEMENT 

EMPLOYED  ON  THE  ENLARGED  UTERUS  -     155 

XI.  THE  AVOIDANCE  OF  HAEMORRHAGE  AND  INJURY  TO  NEIGH- 
BOURING ORGANS  DURING  MORCELLEMENT   -  ~     1 59 

XII.    COMBINED   METHODS  -       l6l 

PART    III. 
THE  AFTER-TREATMENT. 

I.    AFTER-FEEDING  :    REGULATION   OF    BOWELS   AND    BLADDER 

— TEMPERATURE — SECONDARY    HAEMORRHAGE  -       165 

EXPLANATIONS   OF   THE    ILLUSTRATIONS     -  173 

LIST   OF   THE    ILLUSTRATIONS  -  -  -  -  ix 


LIST  OF  ILLUSTRATIONS. 


FIG.  FACiE 

I.  OPERATING  -  TABLE,  SLIGHTLY  ELEVATED.  IN  THE 
VAGINAL  RADICAL  OPERATION  THE  LEG-HOLDERS  ARE 
TO  BE  REMOVED  -  -  57 

3-16.    VAGINAL   RADICAL   OPERATION    APPLIANCES         -          62,  63,  65 

17.  FIXING   THE    PORTIO    VAGINALIS  -         69 

1 8.  COMMENCEMENT   OF    THE    CIRCULAR    INCISION    ON    THE 

ANTERIOR  SURFACE  OF  THE  CERVIX,  THE  NECK  BEING 
DRAWN  OUT  OF  THE  VULVA  WITH  VOLSELL^E  -  72 

19.  DIAGRAM    OF   THE    COURSE    OF   THE   URETERS    (LUDWIG 

PICK)  -         82 

20.  INTRODUCTION  AND  SPREADING  OF  THE  SCISSORS  IN 

OPENING  THE  UTERO-VESICAL  POUCH  -      87 

21.  EVULSION  OF  THE  FUNDUS  FROM  THE  PELVIC  CAVITY      89 

22.  OPENING   THE  POUCH  OF  DOUGLAS   BY  THRUSTING  A 

FORCEPS  THROUGH  FROM  ABOVE      -  91 

23.  UTERUS,    WITH    THE    APPENDAGES    OF    BOTH    SIDES, 

DRAWN  DOWN  INTO  THE  VAGINA  ;  THE  RIGHT  AP- 
PENDAGES SEIZED  WITH  AN  OVARIAN  FORCEPS  -  92 

24,  25.  APPLICATION  OF  CLAMPS  FROM  BELOW,  DIAGRAMMATIC 

(DR.  VOGEL)  95,  96 

26,  27.  THE  DANGER  OF  APPLYING  THE  CLAMPS  PARTLY  FROM 
ABOVE  AND  PARTLY  FROM  BELOW,  DIAGRAMMATIC 
(DR.  VOGEL)  97,  98 

28.  APPLICATION   OF   THE   FIRST   CLAMP   ON    THE   RIGHT 

ADNEXA,  THE  LEFT  FOREFINGER  BEHIND  THE  RIGHT 
BROAD  LIGAMENT  -  -  IOO 

29.  CLAMPING  OF  THE   OTHER  SIDE,  ACCORDING  TO  THE 

FIRST  METHOD  -     IO2 

30.  EXPOSURE  AND  SPREADING  OUT  OF  THE  WOUND  BY 

THE  CLAMPS  AND  RETRACTOR  -  -  106 


LIST  OF  ILLUSTRATIONS 


FIG.  PAGE 

31.  INTRODUCTION  OF  THE  CENTRAL  STRIP  OF  GAUZE  1 09 

32.  PREVENTIVE  CLAMPING  OF  THE  LEFT  UTERINE  VESSELS     Il8 

33.  FIXATION   OF   THE  PORTIO  VAGINALIS  FOR  ANTERIOR 

MEDIAN  SECTION  -     124 

34.  THL   UNROLLING   OF   THE   UTERUS   RESULTING    FROM 

SECTION  OF  ITS  ANTERIOR  WALL     -  125 

35.  THE  DELIVERY  OF  THE  ADNEXA  OF  BOTH  SIDES  AFTER 

COMPLETE  MEDIAN  SECTION  OF  THE  UTERUS  -  131 

36,  37.  THE  TWO  POSITIONS  OF  THE  LEFT  BROAD  LIGAMENT 

AFTER  COMPLETE  MEDIAN  SECTION  OF  THE  UTERUS 

(DR.  VOGEL)  132,  133 

38.  APPLICATION  OF  THE  CLAMPS  ON  THE  LEFT  SIDE  IN 

THE  POSITION  SHOWN  IN  FIG.  36  -  134 

39,  40.  VAGINAL  RADICAL  OPERATION  WITH  COMPLETE  MEDIAN 

SECTION  OF  THE  UTERUS     -  136,  137 

41.  MORCELLATION    OF    THE    ANTERIOR    WALL    OF    THE 

UTERUS  BY  REMOVAL  OF  VERTICAL  STRIPS  -  -  139 

42.  DOYEN'S  METHOD  OF  MORCELLEMENT  (AFTER  DOYEN)  141 

43.  SECOND'S  METHOD  OF  MORCELLEMENT — FINAL  STAGE  142 

44.  IRREGULAR    MORCELLEMENT    OF    A    UTERUS    ONLY 

SLIGHTLY  ENLARGED  -  -     152 

45.  CENTRIPETAL   MORCELLEMENT  OF  A  FIBROID  OF  THE 

BODY  OF  THE  UTERUS  -  -     158 

46.  VAGINAL   RADICAL   OPERATION    BY   THE   MIXED   PRO- 

CEDURE -  -       162 

47.  ABDOMINO- VAGINAL   RADICAL   OPERATION  -       163 


PART  I. 

THE  DEVELOPMENT  OF  THE  VAGINAL  RADICAL 
OPERATION. 


CHAPTER  I. 

HISTORY    OF    REMOVAL    OF    THE    UTERUS    UP    TO 
THE    TIME    OF    PEAN. 

THE  technique  of  the  removal  of  the  womb,  with  its  appen- 
dages, has  acquired  an  undreamed-of  perfection  in  the  last  few 
years,  and  the  indications  for  the  operation  have  been  greatly 
extended.  The  advances  made  in  the  technique  furnish  in 
certain  classes  of  diseases  a  more  certain,  and  in  many  the 
only,  method  of  cure.  The  severest  inflammatory  diseases 
of  the  internal  genital  organs,  all  the  benign  and  the  greater 
part  of  the  malignant  tumours  of  and  about  the  uterus,  have 
been  brought  within  reach  of  the  surgeon's  knife,  whilst  in 
two  other  respects  the  removal  of  the  womb  represents  an 
important  advance  in  the  science  of  gynaecological  surgery. 

Firstly,  the  development  of  vaginal  hysterectomy  has 
brought  to  our  knowledge  the  great  value  of  hysterectomy 
as  an  exceedingly  efficient  means  of  abdominal  drainage. 
Secondly,  single  steps  of  the  operation  have  branched  off 
from  the  path  along  which  the  modern  method  of  extirpa- 
tion was  developing,  and  have  become  independent,  con- 
servative vaginal  operations.  At  the  same  time  we  must 
admit  that  with  regard  to  these  latter — anterior  and  posterior 
vaginal  cceliotomy,  vagino-fixation,  etc. — their  indications 


THE   VAGINAL  RADICAL  OPERATION 


have  been  enormously  extended,  and  their  real  value  greatly 
over-estimated. 

The  advance  in  the  technique  of  uterus  extirpation  seems 
for  the  present  to  have  reached  a  resting-point ;  and  as  it 
has  been  our  intention  for  some  time  to  describe  our  method 
in  full,  the  present  seems  a  fitting  occasion,  and  in  the  fol- 
lowing pages  we  shall  enumerate  the  principles  and  details 
of  the  vaginal  extirpation  of  the  uterus  and  appendages  as 
practised  by  us.  The  abdominal  and  combined  operations 
will  be  discussed  in  another  place. 

In  this  work  the  description  of  the  technique  will  naturally 
include  a  consideration  of  the  scope  and  indications  of  the 
vaginal  operation.  Theoretical  discussion,  except  when  based 
on  our  observation  and  experience,  will  be  omitted.  Inas- 
much as  we  regard  our  position  in  this  matter  as  being  new 
and  original,  we  must  necessarily  review  the  development 
and  history  of  extirpation  of  the  uterus. 

The  beginning  of  this  development  dates  from  the  time 
of  the  publications  of  Freund1  (1878)  and  Czerny2  (1879). 
Previous  to  this  time  only  isolated  and  tentative  efforts  had 
been  made  by  a  few  daring  operators,  each  time  to  be 
brought  to  a  halt  by  the  general  opinion  of  the  profession, 
expressed  in  speech  and  writings.  Excepting  inversion  of 
the  uterus,  for  which  Ambroise  Pare3  as  early  as  1575  per- 
formed an  extirpation  —  probably  but  partial  —  carcinoma 
alone,  on  account  of  its  frequency  and  its  fatal  course,  could 
induce  the  surgeon  to  take  up  the  knife,  and  then  only  as  a 
last  resort.  There  is  no  doubt  that  the  early  procedures  for 
extirpation  of  the  uterus  were  so  nearly  complete  and  perfect 
that  technically  the  vaginal  operation  of  to-day  has  not  very 
much  new  to  offer.  In  1809  Struve4  proposed  the  following 
operation  for  carcinoma  uteri  :  '  to  prolapse  and  draw  the 
womb  down  with  a  forceps,  separate  the  vaginal  portion  by 
means  of  a  circular  incision,  ligature  the  vessels,  and  sever 
the  womb  from  the  ligaments ' — a  good  representation  of 

1  W.  A.  Freund,  Volkmann's  'Sammlung  klinischer  Vortrage,'  No.  133. 

-  Czerny,  '  Wiener  med.  Wochenschrift,'  1879,  Nos.  46,  49. 

3  A.  Franchomme,  'Journal  des  sc.  mdd.  Lille,'  June  i,  1895. 

4  '  Hufeland'sche  Journal,'  Band  16,  St.  3,  p.  123. 


HISTORY  OF  THE  OPERATION  13 

the  ligature  method  now  in  use.  Ten  years  later  followed 
Langenbeck's  celebrated  publication,1  and  the  opinion  of  his 
opponents  was  embodied  in  the  merciless  criticism  of  Johann 
Jorgs  immediately  afterwards.  Even  the  partial  excision  of 
the  uterus,  which  was  recommended  at  about  the  same  time, 
especially  by  Osiander,  received  but  little  favour  from  him. 
Subsequent  attempts  were  purely  sporadic,  and  were  asso- 
ciated with  the  names  of  Wolf,  Sauter,  Blundel,  Recamier, 
Roux,  Paletta,  von  Siebold,  Dubled,  C.  Wenzel,  Gendrin, 
Gutberlet,  and  Delpech.  The  methods  used  wrere  as  different 
as  the  writers  themselves.  One  operated  with  the  ligature, 
another  employed  punk  or  charpie  as  a  haemostatic  ;  one 
operated  only  upon  prolapsed  uteri,  a  second  produced  this 
artificially,  and  a  third  operated  with  the  organ  in  situ; 
some  employed  the  vaginal  method,  others  exclusively  the 
abdominal,  whilst  others,  again,  combined  the  two.  And 
what  did  all  their  efforts  accomplish  ?  For  the  answer  let 
us  read  Dieffenbach.2 

This  the  greatest  German  surgeon  of  his  time  says  in  the 
chapter  on  the  extirpation  of  the  uterus  :  '  To  take  the  entire 
womb  from  the  belly  of  a  woman  means  the  removal  of  that 
woman's  soul,  even  if  it  be  a  diseased  soul,  a  thought  at 
which  every  human  being  quakes.  The  extirpation  of  the 
whole  uterus,  an  organ  so  important  to  the  female  organism, 
is  really  as  great  an  operation  as  the  removal  of  the  spleen, 
kidney,  or  any  other  diseased  organ.  Still,  some  daring 
men  have  attempted  it,  and  they  deserve  our  thanks,  inas- 
much as  the  results  of  their  terrible  operations  furnish  us  all 
the  proof  needed  to  banish  this  procedure  from  the  field 
of  surgery.  .  .  .  According  to  my  opinion,  an  indication 
for  this  operation  does  not  exist.  The  attempted  extirpa- 
tions of  the  womb  partake  more  of  the  character  of  murder 
tales  than  of  curative  surgical  operations.'  Again  (p.  799) : 
'  The  principle  is  entirely  false  when  we  try  to  bestow  the 
full  rights  of  surgical  citizenship  on  any  great  operation 

1  Theodor    Landau,    '  Totalexstirpation    d.    krebsigen    Gebarmutter,' 

1893- 

2  J.  Fr.  Uieffenbach,  '  Die   operative  Chirurgie,'  Bd.   2,  pp.   794-799, 
1848. 


i4  THE  VAGINAL  RADICAL  OPERATION 

merely  because  somebody  has  once  survived  it.     Sauter  had 
the  good  fortune  to  have  a  patient  recover,  from  whom  he 
had  removed  the  uterus  ;   all  other  patients,  however,  have 
reaped  nothing  but  deatfy  and  this,  too,  after  suffering  from 
the  most  frightful  of  all  diseases,  and  undergoing  the  most 
terrible  operation.     Further  massacres  of  this  sort  must  not 
be  attempted,  even  with  the  help  of  sulphuric  ether.     What 
has  succeeded  at  one  time  will  not  necessarily  do  so  again. 
If  the  English  coachman  recovered  after  a  carriage-pole  had 
been  driven  right  though  his  chest,  or  the  American  sailor 
lived  after  an  anchor-hook  had  penetrated  his  belly,  it  was 
only  by  a  chance,  harder  to  secure  than  to  win  the  grand 
prize  in  a  lottery.     No   doubt   the  awful   reports  will    not 
prevent  some  surgeon  from  devising  a  new  method  of  extir- 
pating the  uterus ;    much    better   it  would   be   if  someone 
would   teach    us   how   to    cure    cancer   of  the   womb   with 
medicine.     Methods  of  extirpating  the  uterus    easier   than 
the   ones   now   in    use  will   hardly  be  discovered ;    for  the 
inaccessibility  of  this  organ,  its  important  connections,  and 
the  disease  itself,  will  always  remain  the  same.     Other  and 
better  incisions  are  not  possible,  and  the  severest  injuries 
of  the  neighbouring  organs  (such  as  the  bladder)  often  occur 
in  the  most  experienced  hands.     Finally,  the  dreadful  result 
of  these  procedures  suggested  to  surgeons  the  unfortunate 
idea  of  removing  the  diseased  uterus  through  the  abdomen, 
and  yet  the  greater  part  of  the  operation  had  to  be  made 
from  below.     Speedy  death  for  the  patient  was  the  result  of 
this  undertaking.    It  is  to  be  hoped  that  the  terrible  eminence 
to  which  this  operation  has  now  attained  will  be  the  cause 
of  its  eternal  ruin.' 

Through  such  terrifying  warnings  all  surgical  efforts  directed 
to  the  removal  of  the  uterus  fell  into  disrepute,  and  the 
paucity  of  the  adherents  of  hysterectomy  during  the  following 
decade  is  easily  accounted  for.  All  the  more  honour  there- 
fore to  those  who,  in  spite  of  all  opposition,  and  when  con- 
fronted with  the  most  hopeless  of  diseases,  carcinoma,  had 
the  courage  of  their  convictions,  and,  undismayed  even  by 
their  own  unfavourable  results,  strove  by  word  and  deed  for 
the  perfecting  and  extension  of  their  operation. 


HISTORY  OF  THE  OPERATION 


In  the  history  of  the  extirpation  of  the  uterus,  Kieter  (1848) 
and  Reiche1  (1854)  deserve  mention,  the  latter  especially,  who 
operated  seven  times.     Although  none  of  his  patients  lived 
more  than  a  few  weeks,  yet  he  strenuously  advocated  the 
repetition  of  total  extirpation  with  the  aid  of  chloroform, 
which  was  then  just  coming  into  use.     But  the  operation 
was  not  yet  ready  for  revival,  and  in  1874  Hegar  and  Kalten- 
bach2  once  more  condemned  it.     '  In  the  last  few  years  total 
extirpation  has  not  been  performed,  not  only  because  the 
former  methods  have  been  discarded  as  being  too  dangerous, 
but  because  the  cases  which  offer  even  a  slight  chance  of 
success  after  such  an  energetic  operation  are  extremely  rare.' 
Now  begins  the  new  era  in  the  history  of  hysterectomy — 
an  era  stamped  with  the  names  of  W.  A.  Freund  and  Czerny. 
One  of  the  chief  difficulties  in  the  way  of  the  surgeon  had 
been  the  view  that  cancer  was  a  dyscrasia  ;  for,  according  to 
this  theory,  the  removal  of  the  tumour  could  only  be  regarded 
as  a  useless  beginning.     Virchow's  researches  destroyed  the 
foundation  of  this   idea,   and  carcinoma  now  came   to   be 
recognised  as  a  disease  primarily  local — a  disease  therefore 
susceptible  to  local  treatment,  and  indeed  curable.    At  about 
the  same  time,  the  new  principles  of  wound  treatment  in- 
troduced by  Pasteur  and  Lister  offered  fresh  encouragement 
to  operative  measures,  which  had  been  previously  hopeless. 
All   procedures   directed   to   the   extirpation    of  the   uterus 
seemed  henceforth  justified,  if  it  were  possible  to  overcome 
the  purely  technical  difficulties  ;  and  here  it  was  that  Freund's 
work  laid  the  foundations  of  abdominal  hysterectomy,  as  did 
Czerny's  for  the  vaginal  operation.     The  types  which  they 
gave  us  then  have  remained  types  ever  since,  and  have  lost 
nothing  of  their  originality,  nothing  of  their  effectiveness. 
And  this  in  spite  of  a  great  series  of  modifications,  as  the 
most   important  of  which  we   consider   Bardenheuer's   ab- 
dominal drainage,  and  Doyen's  ingenious  modification  bearing 
on  the  separation  of  the  bladder  and  ureters  from  the  .genital 
tract  in  the  abdominal  extirpation.     Freund's  earliest  com- 
munications on  total  extirpation  of  the  uterus  gave  us,  in  a 

1  Reiche,  '  Exstirpatio  uteri,'  '  Deutsche  Klinik,'  Bd.  6,  p.  484,  1854. 

2  Hegar    and    Kaltenbach,    'Operative    Gynakologie,'    third    edition, 
p.  217,  1886. 


16  THE  VAGINAL  RADICAL  OPERATION 

finished  and  elaborated  form,  the  important  fundamental 
principles  of  the  technique  for  all  further  abdominal  or 
abdomino-vaginal  procedures  —  namely,  formation  of  the 
pedicles  from  the  broad  ligaments,  their  inversion  into  the 
vagina,  and,  finally,  transference  of  the  whole  wound  surface 
from  abdomen  to  vagina,  changing  it  from  intra-  to  extra- 
peritoneal.  Freund  deserves  all  the  more  credit  from  the 
fact  that  he  tested  and  successfully  executed  his  method 
under  the  most  technically  unfavourable  circumstances — the 
abdominal  total  extirpation  of  a  cancerous  uterus,  which  was 
purulent,  fixed,  and  not  enlarged. 

The  extension  of  the  indications  for  the  vaginal  operation 
has  kept  pace  with  its  rapid  adoption,  so  that  total  extirpa- 
tion is  now  employed  not  only  for  carcinomata,  but  also  for 
myomata  and  for  uncontrollable  idiopathic  uterine  haemor- 
rhage without  gross  anatomical  lesions. 


CHAPTER  II. 
PEAK'S  IMPROVEMENTS — PEAN'S  OPERATION. 

PEAN's1  attempt  to  do  away  with  all  sutures  for  the  control 
of  haemorrhage,  and  to  use  clamps  instead,  was  an  improve- 
ment of  very  great  importance  in  the  technique  of  the 
vaginal  operation.  He  had  repeatedly  employed  this  form  of 
haemostasis  in  other  operations2 ;  but  the  first  time  he  used 
it  upon  the  uterus  to  the  exclusion  of  the  older  method  was 
on  August  21,  1885,  for  the  removal  of  a  cancerous  womb. 
A  year  later,  July  21,  1886,  after  many  attempts  to  combine 
the  clamp  and  the  suture  methods,  he  formally  advocated 
the  former  method  of  hasmostasis  as  a  distinctive  principle 
in  total  hysterectomy.3  Richelot's  name  also  should  be 
associated  with  this  method ;  his  part  in  the  development  of 
haemostasis  by  forcipressure  is  best  given  by  himself  in  the 
paper  read  by  him  before  the  French  Surgical  Congress, 
October  19,  1886.  He  said  :  '  In  the  employment  of  the 

1  'Bullet,  de  la  Soc.  de  Chirurg.,'  November  11,  1885. 

2  '  Legons  de  Clinique  Chirurgicale,'  1876. 

3  '  Gaz.  des  Hopit.,'  April  20,  1889. 


PEAN'S  OPERATION  17 


clamps,  I  know  that  I  have  made  no  new  discover)-,  and  my 
claim  of  priority  is  limited  to  the  following  point :  Systematic 
and  exclusive  use  of  them  in  place  of  all  ligatures,  this  not 
for  the  sake  of  convenience  or  in  difficult  cases,  but  in  every 
case  as  the  method  of  election.'  As  a  fact,  Pean  had  occa- 
sionally used  the  ligature  or  the  ligature  and  clamp  method 
between  August,  1885,  and  July  21,  1886  ;  Richelot  not  since 
July  8,  1886. 

Spencer  Wells  (1882)  and  Jennings  (1885) l  have  been  con- 
sidered by  some  writers  as  the  originators  of  haemostasis  by 
forcipressure  as  applied  to  hysterectomy  ;  but,  as  we  intend 
to  show,  M.  B.  Freund2  is  really  the  projector  of  this  im- 
portant advance.  After  a  series  of  experiments  on  the  cadaver, 
he  recommended  theoretically,  in  1881,  the  use  of  clamps  in 
the  place  of  sutures  and  ligatures.  '  The  difficulties  in  the 
way  of  handling  the  broad  ligaments  suggested  the  thought 
of  securing  them,  in  their  continuity,  with  suitable  compres- 
sion forceps  which  could  remain  in  place  for  a  time.'  '  These 
instruments  are  similar  to  the  Pean  forceps ;  but,  to  prevent 
their  slipping,  one  blade  is  provided  with  a  groove,  into 
which  fits  a  convexity  on  the  opposite  blade.  They  are  in- 
troduced from  the  vagina,  and  clamped  on  to  the  broad 
ligament  at  each  side,  lying  close  to  and  parallel  with 
the  uterus/  '  The  experiment  of  allowing  these  to  lie  for 
several  days  in  the  pelvic  cavity '  seemed  to  Freund  quite 
permissible. 

In  this  connection  it  is  also  worthy  of  notice  that,  in  the 
same  work  (1881),  he  mentions  a  method  especially  adapted 
to  the  removal  of  the  cancerous  womb — a  method  that  has 
since  been  '  discovered,'  nobody  knows  how  many  times : 
the  use  of  the  actual  cautery.  He  used  this  first  to  incise 
the  vaginal  vault,  and  then,  after  the  clamps  were  in  place, 
to  sever  the  broad  ligaments  inside  the  forceps. 

In  France  the  method  of  using  clamps  in  hysterectomy 
rapidly  gained  many  adherents,  such  as  Bouilly,  Quenu, 
Terrier,  Segond,  Michaux,  Nekton,  Doyen,  etc.  In  other 

1  Pozzi,  '  Gynecologic,'  p.  401,  1890. 

2  'Zeitschrift  f.  Geburt.  u.  Gynak.,'  Bd.  6,  iSSi. 


j 8  THE  VAGINAL  RADICAL  OPERATION 

countries,    Mueller1  of  Switzerland   and    L.   Landau2  were 
among  the  first  to  advocate  the  plan. 

Since  then,  outside  of  our  own  school  in  Germany,  we 
have  found  but  few  advocates  of  this  procedure ;  whilst  in 
many  articles,  from  numerous  opponents,  a  few  weak  and 
theoretical  objections  to  the  method  periodically  appear.  It 
is  only  the  use  of  the  clamps  that  has  extended  the  indica- 
tions for  the  vaginal  operation  previously  based  on  the  Czerny 
method,  and  a  uterus  immobilized  by  carcinomatous  or  in- 
flammatory infiltration  can  now  be  removed  by  the  vaginal 
route  regardless  of  these  complications,  and  without  having 
recourse  to  extensive  accessory  procedures.3 

Then  Pean's  morcellement,  which  this  surgeon  brought 
into  use  more  than  thirty  years  ago  for  the  removal  of  large 
deep-seated  abdominal  tumours,  showed  us  the  way  of  over- 
coming the  difficulties  attendant  on  the  vaginal  extirpation 
of  enlarged  uteri.  So,  from  the  two  improvements  intro- 
duced by  Pean,  the  clamp  and  morcellement,  the  rather 
limited  field  of  the  old  (Czerny)  suture  method  was  broadened 
in  every  direction  in  a  manner  and  extent  corresponding  to 
the  advances  in  the  methods. 

At  first  the  total  extirpation  of  the  cancerous  womb  was 
undertaken  only  when  one  had  to  deal  with  a  mobile  organ 
of  normal  size,  in  which  the  malignant  growth  was  limited 
strictly  to  the  uterus.  Gradually,  however,  in  the  same  way 
and  under  the  same  conditions — mobility,  normal  size — the 
operation  began  to  be  adopted  in  certain  cases  for  prolapse, 
small  myomata,  and  uncontrollable  haemorrhage  from  the 
endometrium.  Then,  with  the  aid  of  Pean's  improvements, 
the  list  of  operable  cases  was  enlarged  to  include  immobile 
and  enlarged  uteri  regardless  of  the  causal  factor — myoma, 
carcinoma,  etc. 

And  now  it  is  Pean  who  again  appears  on  the  scene  with 
a  third  important  modification  of  the  technique  of  vaginal 
hysterectomy,  an  improvement  which  makes  the  extirpation 

1  '  Centralblatt  f.  Gynak.,'  1882,  No.  12. 

2  'Berlin  klin.  Wochenschrift,'  1888,  No.  10. 

3  L.   Landau,    Internal.  Med.  Congress,  Vol.    III.,  Part   viii.,   p.    51, 
ct  seg.,  1891. 


FURTHER  ADOPTION  OF  PEAN'S  OPERATION          19 

of  the  uterus  not  only  a  direct,  but  also  an  indirect  curative 
operation.  With  Pean  originated  the  removal  of  the  uterus  as  a 
remedy  for  diseases  of  the  adnexa. 


CHAPTER  III. 

THE    FURTHER   ADOPTION    OF    PEAN'S    OPERATION ITS  INDIS- 
CRIMINATE     USE  DEVELOPMENT     OF       THE       VAGINAL 

RADICAL    OPERATION. 

WITH  a  few  words  more  we  will  complete  the  history  of 
Pean's  operation.  Among  those  who  assisted  in  its  introduc- 
tion and  further  employment,  the  names  of  Segond  and  Doyen 
stand  out  pre-eminently.  Others  working  along  this  line 
were  Richelot,  Bouilly,  Nelaton,  Quenu,  Reclus,  and  Routier 
in  France  ;  Jacobs,  Rouffart,  and  Debaisieux  in  Belgium  ; 
Iversen  in  Denmark;  Treub  in  Holland;  Acconci,  Bastianelli, 
Inverardi,  Ruggi  in  Italy;  L.  and  Th.  Landau  in  Germany. 
Of  other  German  operators  favouring  this  or  the  clamp 
method  we  know  only  C.  Abel,  Rather,  and  Schramm  up  to 
the  present  time. 

The  Brussels  International  Gynaecological  Congress,  Sep- 
tember, 1892,  marks  an  important  epoch  in  the  development 
of  this  procedure.  Here  for  the  first  time  the  question  of 
'  Pean's  operation '  was  brought  before  a  large  body  of 
specialists,  and  thoroughly  and  extensively  discussed.  An 
evidence  of  its  wide  adoption  since  that  time  is  to  be  seen  in 
Lafourcade's  dissertation  in  1893,  in  which  he  cites  138  cases 
collected  from  various  sources.1 

At  that  time,  however,  in  spite  of  the  rapidly-accumulating 
literature  on  the  subject,  and  in  spite  of  the  valuable  system- 
atizing, it  was  difficult  from  the  published  reports  to  estimate 
clearly  the  real  value  of  the  operation,  or  to  defend  it  against 
the  many  objections  urged  by  its  opponents.  The  one 
common  feature  of  the  individual  communications  of  the 

1  J.  Lafourcade,  '  De  1'hysterectomie  vaginale  dans  les  suppurations 
Pe"riuterines.'  These  de  Paris,  1893. 

2 — 2 


20  THE  VAGINAL  RADICAL  OPERATION 

writers  often  consisted  in  the  discussion  of  the  technique, 
to  the  neglect  of  the  other  points  involved ;  their  writings 
were  mostly  in  the  form  of  collective  reports,  details  being 
almost  or  entirely  neglected.  The  most  striking  of  all  was 
the  vague  and  hazy  manner  in  which  the  indications  were 
considered ;  the  overworked  term  '  pelvic  suppuration  '  was 
on  duty  everywhere,  and  was  apparently  considered  quite 
sufficient. 

Under  this  title  were  included  a  host  of  other  pelvic  sup- 
purative  diseases  besides  the  '  suppurations  graves  periute- 
rines'  for  the  cure  of  which  Pean  had  devised  this  operation. 
Certainly  many  unimportant  and  many  actually  non-suppura- 
tive  cases  were  subjected  to  this  operation,  and  it  seemed  that 
the  less  the  organs  were  diseased,  the  more  readily  were  they 
extirpated. 

The  indications  given,  loosely  expressed  as  '  pelvic  sup- 
puration,' were  always  devoid  of  a  definite  pathologico- 
anatomical  basis ;  there  was  but  little  attempt  at  individ- 
ualization ;  in  other  words,  the  exact  clinical  diagnosis  was 
omitted.  This  criticism  does  not  spring  from  a  mania  for 
theoretical  classification,  but  is  the  recognition  of  the  fact 
that  only  from  a  proper  sorting  of  the  cases  can  a  suitable 
differential  system  of  treatment  be  established. 

On  these  three  points — the  pathologico-anatomical  classifi- 
cation of  pelvic  abscesses,  their  clinical  diagnosis,  and  their 
wholly  individual  treatment — we  have  already  insisted  in  a 
series  of  articles  published  elsewhere.1 

In  classifying  these  diseases  anatomically,  without  regard 
to  their  specific  origin  or  to  the  nature  and  method  of  infection 
and  diffusion,  the  intra-  are  to  be  distinguished  from  the  extra- 
peritoneal  abscesses.  Under  the  latter  are  those  in  preformed 
cavities  (pyometra,  pyosalpinx,  pyo-ovarium),  and  those 
lying  within  a  tissue,  paravaginal  and  parametric  cellular 
tissue,  and  pelvic  and  abdominal  subperitoneal  connective 
tissue.  They  may  be  single  or  multiple,  and  are  often 
bilateral.  The  two  forms  are  seldom  found  separate  ;  usually 

1  L.  Landau,  'Arch.  f.  Gynakol.,'  Band  46,  Heft  3.      'Berliner  Klin. 
Woch.,'  No.  22-24,  1894.     '  Tubensacke,'  Berlin,  1891. 


FURTHER  ADOPTION  OF  PEAN'S  OPERATION  21 

intra-  and  extra-peritoneal  abscesses  occur  side  by  side. 
Subperitoneal  pelvic  cellulitis  is  generally  associated  with  an 
inflammation  of  the  overlying  peritoneum,  forming  in  this 
way  the  first  stage  of  intra-peritoneal  abscesses. 

The  varieties  of  acute  pelvic  peritonitis  are  the  serous, 
fi'brinous,  purulent,  and  haemorrhagic.  Chronic  adhesive 
pachypelviperitonitis  often  occurs  alone  as  a  result  of  the 
above,  or  in  combination  with  serous  cysts,  or  with  encap- 
sulated intra-  and  extra-peritoneal  abscesses.  From  these 
forms  of  inflammatory  and  suppurative  pelvic  peritonitis  there 
are  developed  various  combinations,  all  of  which  are  sus- 
ceptible of  diagnosis  and  of  differential  treatment. 

In  the  above  conditions  L.  Landau  (loc.  cit.)  has  called 
attention  to  the  different  clinical  signs,  and  has  especially 
used  and  recommended  exploratory  puncture  and  incision 
into  the  vaginal  vault  as  diagnostic  aids.  By  their  use  we 
were  enabled  to  solve  the  mystery  of  that  venerable  and 
intangible  '  parametric  disease  '  as  well  as  parametric  indura- 
tions and  chronic  parametritis,  and  place  them  in  their  proper 
category.  Many  a  parametric  tumour  whose  stony  hard- 
ness might  have  justified  the  diagnosis  of  uterine  enlarge- 
ment, or  even  fibroid,  has  in  this  way  been  demonstrated  to 
be  an  encapsulated  intra-peritoneal  abscess,  a  thickened 
pyosalpinx  or  an  extra -peritoneal  abscess  with  a  dense 
capsule. 

From  the  clinical  and  anatomical  data  at  hand,  we  propose 
the  following  basis  and  outline  of  treatment  for  the  so-called 
'  pelvic  suppuration  ' : 

1.  Sharp  distinction  to  be  made  between  unilateral  and 
bilateral  diseases,  and  between  single  and  multiple  abscesses. 

Removal  of  the  uterus  only  in  case  of  bilateral  suppuration 
and  destruction  of  the  adnexa. 

2.  Incision  of  solitary  abscesses,  from  vagina  or  abdomen, 
according  to  their  location. 

In  case  of  multilocular  abscess  involving  one  side  only, 
removal  of  the  corresponding  diseased  appendages. 

3.  For  bilateral   unilocular   abscesses   simple  incision  is 
first  to  be  tried.     This  procedure,  even  in  double  unilocular 
pyosalpinx,    when   unsuccessful,    does    not   complicate   any 


22  THE  VAGINAL  RADICAL  OPERATION 

operation    which    may   later   become    necessary,    and    may 
preserve  important  functions. 

4.  In  bilateral  disease  of  the  appendages  with  multi- 
locular  pus  collections  (double  multilocular  pyosalpinx,  tubal 
abscess  associated  with  intra-  and  extra-peritoneal  abscesses, 
etc.)  the  mere  extirpation  of  the  adnexa  by  the  abdominal 
or  vaginal  route  is  not  to  be  advised,  for  recovery  from  the 
operation  does  not  guarantee  recovery  from  the  disease.  In 
these  cases,  and  also  in  bilateral  abscesses  with  fistulous 
communication  with  neighbouring  organs,  the  vaginal  radi- 
cal operation — that  is,  the  total  extirpation  of  the  uterus 
and  appendages  (by  the  vaginal  route  alone,  whenever  pos- 
sible)— finds  its  special  application. 


CHAPTER  IV. 

THE  VAGINAL    RADICAL  OPERATION  :    ITS   DEFINITION,  LIMITS, 

INDICATIONS,    AND    ADVANTAGES THE    PRINCIPLES    AND 

TECHNICAL   AIDS    OF    OUR    OPERATION. 

THE  method  proposed  and  employed  by  us  in  the  treatment 
of  the  cases  above  mentioned  is  the  one  we  designate  as  the 
vaginal  radical  operation  (the  castration  utero-ovarienne, 
utero-annexielle  or  totale  of  French  authors).  The  cases  in 
which,  as  a  last  resource,  we  first  tried  the  operation  were 
complicated  pelvic  abscesses. 

A  detailed  description  of  the  peculiarities  of  these  cases, 
the  results  obtained  by  this  method,  and  the  relation  of  this 
to  other  methods  of  removal  of  the  uterus,  have  been  given 
by  us  in  previous  writings  (loc.  cit.). 

A  review  of  these  reports  must  convince  every  unprejudiced 
reader  that  the  operation  was  employed  upon  patients  who 
were  otherwise  practically  incurable,  cases  in  which  any 
other  operation  would  have  been  unusually  dangerous,  and 
for  which,  therefore,  the  vaginal  radical  operation  was  the 
final  and  only  remedy.  In  all  these  cases  the  disease  was  of 
several  years'  duration  ;  many  had  previously  undergone 
various  operations  with  temporary  benefit,  incision,  resection 


INDICATIONS  AND  ADVANTAGES  OF  THE  OPERATION    23 

of  the  uterus,  laparotomy,  etc.  Several  of  these  women  had 
fistulse  communicating  with  bladder  and  rectum.  For 
such  conditions  the  operation  was  the  only  efficient  pro- 
cedure :  it  was  the  method  of  necessity,  not  of  choice. 

We  next  employed  the  vaginal  radical  operation  in  cases 
of  uncomplicated  bilateral  suppurative  disease  (such  as 
pyosalpinx  and  suppurating  ovarian  cysts),  when  attempts  at 
conservative  medical  and  surgical  treatment  had  failed, 
instead  of  the  mere  removal  of  the  appendages  alone.  We 
were  led  to  this,  not  by  theoretical  considerations,  but  by 
the  experience  gained  in  a  series  of  141  laparotomies  for 
inflammatory  disease  of  the  adnexa.  This  series  included 
63  cases  of  pyosalpinx,  38  of  hydrosalpinx,  6  of  hydro- 
pyosalpinx,  10  of  non-suppurative  salpingitis,  and  24  of 
tubal  pregnancy,  with  a  total  mortality  of  6.  Of  the  fatal 
cases,  two  were  operated  on  for  diffuse  peritonitis. 

At  first  we  limited  the  indications  more  strictly,  and 
employed  the  vaginal  extirpation  only  in  the  severest  cases  ; 
but  later  on,  in  all  cases  of  uncomplicated  bilateral  suppura- 
tive adnexitis,  whenever  extirpation  was  indicated  we  pro- 
ceeded at  once  with  this  operation.  Moreover,  besides  the 
first  series  of  cases  mentioned,  those,  namely,  with  com- 
plicated pelvic  abscesses,  we  had  had  seven  cases  of  severe 
inflammatory  though  non-suppurative  disease  of  the  ap- 
pendages, and  of  tubal  pregnancy,  with  grave  bilateral 
chronic  inflammatory  changes.  In  all  these,  laparatomy 
would  have  been  an  exceedingly  difficult  procedure.  All 
recovered  after  the  vaginal  operation. 

These,  together  with  the  many  suppurative  cases  men- 
tioned, established  for  us  the  indications  for  the  vaginal 
radical-operation,  and  determined  its  use  not  only  as  an 
operation  of  necessity  as  in  complicated  pelvic  abscesses,  but 
also  as  an  elective  procedure  in  uncomplicated  suppurative 
and  non-suppurative  disease  of  the  adnexa,  whenever  and 
wherever  it  was  proved  that  both  sides  were  involved. 

Why  do  we  substitute  the  vaginal  for  the  abdominal  pro- 
cedure, since  we  have  sufficiently  tested  the  latter  ? 

In  the  first  place,  the  permanent  cure  of  the  patient  is  of 
much  greater  concern  to  us  than  merely  having  her  recover 


24  THE   VAGINAL  RADICAL  OPERATION 

from  an  operation.     The  removal  of  the  inflamed  adnexa  by 
the  abdominal  route,  notwithstanding  its  excellent  immediate 
results,  is  really  curative  in  only  a  certain  degree.     That  is, 
but  60  to  70  per  cent,  of  the  cases  so  treated  are  permanently 
relieved  of  the  troubles  for  which  they  were  operated  upon  ; 
they  have  survived  the  operation,  but  are  not  capable  of 
working  or  enjoying  life  ;  the  diseased  appendages  have  been 
taken  away,  but  the  patient  is  not  cured.     The  womb  and 
the  adnexal  stumps  remain,  and  as  the  endometritis,  metritis 
and  parametritis  are  cured  in  only  a  certain  proportion  of 
the  cases,  these  organs  form  a  starting-point  for  recurrent 
pelvic  peritonitis,  and  a  point  of  entry  for  further  peritoneal 
infections.      Old   inflammations   light    up   again,    pyogenic 
bacteria  cause  exudations  in  and  about  the  ligated  stumps, 
or  the  process  takes  on  a  more  chronic  fibre-plastic  character, 
leading  to  the  formation  of  intestinal  and  omental  bands. 
These  are  the  sources  of  the  pain  and  distress  —  constipa- 
tion, chronic  ileus — so  often  occurring  in  patients  who  have 
undergone  laparotomy,  troubles  which  only  removal  of  the 
uterus  can  either  prevent  or  cure. 

Even  if  the  inflammatory  processes  in  and  about  the 
uterus  are  cured  after  the  appendages  of  both  sides  have 
been  removed,  it  still  remains  to  be  shown  that  the  atrophying 
uterus  can  serve  any  useful  purpose  whatsoever  in  the  female 
economy.  On  the  contrary,  a  long  series  of  observations 
enables  us  to  assert  positively  that  the  post-operative 
secondary  symptoms  are  less  after  total  extirpation  than 
after  the  mere  removal  of  the  appendages.  From  a  physio- 
logical standpoint,  therefore,  we  have  no  scruples  about 
removing  the  womb  when  operating  for  bilateral  inflamma- 
tory or  suppurative  disease  of  the  appendages,  or  even  in 
case  of  bilateral  ovarian  tumours.  In  such  cases  the  uterus 
is  for  us  a  negligible  quantity,  and,  apart  from  other  con- 
siderations, is  removed  to  secure  drainage,  exactly  as  one 
sacrifices  a  portion  of  a  sound  rib  in  empyema,  or  a  piece  of 
the  skull  in  draining  a  brain  abscess. 

True,  a  pharisaical  conservatism  declares  the  removal 
of  this  organ  a  sin,  an  organ  which  is  of  no  possible  use, 
and  which  often  causes  damage  curable  only  by  a  later 


INDICATIONS  AND  ADVANTAGES  OF  THE  OPERATION    25 

extirpation.  The  uterus,  when  freed  from  its  appendages, 
is  merely  a  muscular  portion  of  the  abdominal  wall,  especi- 
ally dangerous  as  a  site  for  the  entrance  and  cultivation  of 
virulent  bacteria,  and  later  for  the  development  of  malignant 
tumours. 

In  abdominal  laparotomy  for  inflammatory  or  suppurative 
processes,  the  greatest  caution  sometimes  fails  to  prevent 
the  contamination  of  the  ventral  wound  or  the  peritoneum 
by  the  infectious  material.  The  bacteria  remaining  in  the 
shreds  of  adhesions  in  the  parametric  and  subperitoneal 
tissue  are  still  another  source  of  infection.  Abscess  of  the 
abdominal  wall,  localized  peritonitis,  indurations  and  fistulae, 
furnish  sufficient  proof  of  this  statement.  In  the  vaginal 
operation,  even  when  infectious  material  does  come  into 
contact  here  and  there  with  peritoneum  or  gut  about  the 
field  of  operation,  the  conditions  are  much  more  favourable. 
The  peritoneum  has  retained  its  vitality,  and  has  not  been 
so  bruised  and  maltreated  during  the  operation.  Frequently 
in  the  vaginal  procedure  the  intestine  is  not  even  seen, 
much  less  handled.  Only  the  peritoneum  in  the  immediate 
vicinity  is  disturbed,  and  only  the  organs  which  are  diseased 
and  require  removal,  or  those  structures  in  immediate  contact 
with  them,  are  handled. 

If  we  lay  particular  stress  on  the  absence  of  the  abdominal 
scar  after  the  vaginal  operation,  it  is  not  from  aesthetic 
reasons,  but  on  account  of  the  predisposition  to  hernia  and 
prolapse  of  the  bowel  afforded  by  such  cicatrices.  Un- 
fortunately, with  any  known  method  of  suture  we  can  do 
but  little  to  ensure  against  this  unhappy  complication  ; 
indeed,  the  hernia  may  occur  in  a  stitch  -  hole  alongside 
the  healed  and  solid  line  of  the  incision.  Such  ruptures 
are  not  infrequently  the  cause  of  grave  disturbances,  especi- 
ally when  omentum  and  gut  are  adherent  to  the  scar,  and 
later  to  the  sac,  as  is  often  the  case  after  operation  for  septic 
troubles.  Neither  this  sequel  nor  keloid,  of  which  every 
operator  with  a  large  experience  has  had  instances,  has  as 
yet  been  observed  in  the  scar  left  after  vaginal  extirpation. 

The  amount  of  disturbance  caused  by  the  operation  itself, 
as  well  as  the  risk  of  infection,  is  much  less  in  the  vaginal 


26  THE  VAGINAL  RADICAL  OPERATION 

operation.  The  manipulation  of  peritoneum  and  gut,  with 
fingers,  instruments,  or  dry  or  wet  sponges,  and  the  pulling, 
displacing,  and  cooling  of  the  viscera,  are  done  away  with. 
The  intestines  are  only  interfered  with  when  they  come 
directly  into  the  field  of  the  operation.  Operative  shock  is 
avoided,  convalescence  is  easier  than  after  the  abdominal 
operation,  and  its  duration  is  relatively  and  absolutely 
shortened. 

And  does  not  the  vaginal  operation  exactly  meet  the  re- 
quirements of  the  universal  surgical  principle  which  demands 
open  drainage  for  all  inflammatory  or  suppurative  processes  ? 
In  no  case  of  vaginal  extirpation  do  we  close  the  peritoneal 
sac  ;  the  wound  cavity  is  loosely  packed  with  strips  of  gauze 
about  the  clamps,  and  between  them  and  the  intestines.  All 
secretions  escape  into  the  vagina,  for  it  is  the  most  dependent 
point,  as  well  as  the  natural  outlet.  Drainage  is  easy  and 
certain,  and  much  more  efficient  than  is  ever  possible  by 
the  abdominal  route. 

Another  important  point  in  this  process,  to  which  M. 
Landau  has  called  attention,  is  the  exceedingly  rapid  en- 
capsulation about  the  gauze  which  occurs  on  all  sides  by 
means  of  the  formation  of  adhesions  and  new  membrane. 
In  this  way  the  wound  cavity  shuts  itself  off  from  that  of  the 
peritoneum  to  the  best  advantage,  and  the  rapidly-forming 
secretion  and  demarcation  occur  extra  -  peritoneally.  In 
draining  from  the  abdomen,  the  drainage  tract  is  undoubtedly 
closed  off  in  the  same  rapid  manner,  but  here  the  new 
membranes  are  in  a  less  natural  and  less  desirable  position. 
Definite  adhesions  between  all  the  adjacent  abdominal  organs 
must  be  the  result,  so  also  with  the  abdomino-vaginal  drainage 
which  Chaput1  recommends  especially  for  hysterectomy. 
It  is  a  method  which  offers,  when  compared  with  vaginal 
drainage,  nothing  but  disadvantages,  while  the  latter  is  of 
itself  complete  and  satisfactory. 

It  must  also  be  borne  in  mind  that  the  mode  of  procedure 

of  the  vaginal  radical  operation  allows  of  the  termination  of 

the  operation  at  any  point,  and  especially  in  the  first  stages, 

just  as  well   as  ventral  laparotomy.     Further,  exploratory 

1  '  Sem.  m£dic.,'  p.  349,  1892. 


INDICATIONS  AND  ADVANTAGES  OF  THE  OPERATION    27 

incision  or  removal  of  one  of  the  appendages  only,  in  case  of 
mistaken  diagnosis  of  bilateral  disease,  is  carried  out  easily 
and  without  danger  by  this  method.  In  short,  the  procedure 
can  be  made  as  conservative  as  may  be  desired.  Naturally, 
in  certain  cases  where  the  process  is  not  of  too  severe  a 
nature  (such  as  tubal  pregnancy  or  simple  salpingitis),  the 
uterus  can  be  drawn  forward,  the  appendages  (one  or  both) 
isolated  and  removed,  and  the  womb  then  replaced,  all 
without  any  very  great  technical  difficulty.  But,  on  the 
other  hand,  it  must  not  be  forgotten  that  in  most  cases  the 
diagnosis  can  be  ascertained  before  operation  by  palpation, 
aspiration,  and  observation  of  the  patient,  without  resorting 
to  an  exploratory  incision.  At  least  the  localization  and  the 
inflammatory  or  suppurative  nature  of  the  disease  should  be 
established,  and  the  operation  chosen  in  harmony  with  the 
diagnosis.  From  many  recent  publications,  it  would  seem 
that  in  not  a  few  instances  it  was  only  after  the  begin- 
ning of  the  operation — the  so-called  diagnostic  incision— 
that  patients  have  required  treatment  at  the  hands  of 
gynaecologists. 

A  last  objection,  and  one  that  is  repeatedly  urged  against 
the  vaginal  method,  is  that  inflamed,  purulent,  and  firmly- 
adherent  adnexa  can  be  completely  removed  only  by  ventral 
laparotomy,  and  that  their  extirpation  per  vaginam  can 
therefore  always  be  only  partial.  Indeed,  Pean's  identifica- 
tion of  his  operation  with  the  castratio  uterina  would  seem 
to  strengthen  this  argument,  and  to  mark  this  procedure  in 
every  case  of  diseased  appendages  as  imperfect. 

Even  if  this  were  so,  the  objection  would  be  silenced  by 
the  fact  that  in  a  large  number  of  cases  the  mere  removal  of 
the  uterus  suffices  for  the  certain  and  permanent  cure  of  the 
patient,  because  after  resection  of  the  womb  the  adnexa 
become  completely  atrophied.  Secondly,  Pean  and  Segond 
rightly  view  hysterectomy  as  the  essence  of  their  operation, 
and  not  only  recommend  total  castration,  but  practise  it 
as  well. 

As  a  matter  of  fact,  the  father  of  this  method  (Pean)  in  all 
his  writings  leaves  the  removal  of  the  appendages  to  the 
operator's  discretion  after  the  uterus  is  out  of  the  way.  And 


28  THE   VAGINAL  RADICAL  OPERATION 

Segond  also  states  emphatically  that,  after  the  removal  of  the 
uterus  for  adnexal  diseases,  the  appendages  themselves  are 
only  to  be  extirpated  when  this  can  be  done  easily  and  under 
full  visual  control. 

This  was  another  point  to  which  we  directed  our  efforts  in 
building  up  this  operation ;  like  Doyen,  though  indepen- 
dently, we  demanded  the  radical  execution  of  the  vaginal 
operation  as  such,  that  is,  the  removal  per  vaginam  in 
every  case,  not  only  of  the  diseased  womb,  but  of  the  appen- 
dages— pyosalpinx,  ovarian  abscess — and  the  intra-  and  extra- 
peritoneal  abscess  walls.  The  radical  extirpation  of  the 
diseased  tissue  must  here  be  regarded  as  a  fundamental 
principle,  and  the  authors  were  so  convinced  of  this  that  in 
their  early  operations  abdominal  laparotomy  was  combined 
with  the  vaginal  procedure  in  cases  where  the  radical  opera- 
tion could  not  have  been  completed  by  the  vaginal  route 
alone. 

We  were  first  brought  to  this  radical  method  of  operation  by 
theoretical  considerations,  whose  correctness  was  later  proved 
by  the  results  of  certain  cases  so  treated.  Where,  after  the 
mere  removal  of  the  uterus,  pus  cavities  are  left  in  and  about 
the  diseased  adnexa,  the  involution  of  this  pathological  tissue 
may  be  delayed,  or,  more  seldom,  may  even  not  occur  at  all. 
Suppurating  fistulse  persist  for  months ;  and  even  after  the 
vaginal  wound  has  healed,  the  pelvi-peritonitic  inflammation 
may  light  up  again  about  the  remaining  necrotic  debris  and 
abscess  tissue,  with  the  formation  of  thick-walled  and  tense 
cysts  or  new  abscesses.  Complete  recovery  occurs  then 
only  after  spontaneous  or  artificial  evacuation. 

Indeed,  in  certain  cases  the  patient  is  cured  only  by  a  later 
abdominal  laparotomy,  which,  to  fulfil  the  radical  principle, 
should  have  been  directly  combined  with  the  vaginal  method 
in  the  primary  operation,  instead  of  being  neglected.  The 
greater  the  mass  of  abscess  wall,  pyosalpinx,  or  ovarian 
tissue  left  to  be  eliminated  by  its  own  efforts,  the  more 
extensive  is  the  necrosis  and  demarcation,  the  greater  is  the 
resorption  of  fever-producing  elements,  and  the  more  serious 
is  the  danger  of  secondary  haemorrhage  from  the  erosion  of 
larger  bloodvessels  In  such  cases  a  radical  operation  would 


INDICATIONS  AND  ADVANTAGES  OF  THE  OPERATION    29 

have  rendered  convalescence  shorter  and  easier,  and  made 
the  cure  more  certain. 

The  cases  of  complicated  pelvic  abscesses  first  treated  by 
us — cases  for  which  Pean  and  Segond  had  recommended 
merely  removal  of  the  uterus — showed  in  a  striking  manner 
that  our  emphasizing  the  radical  procedure  in  the  vaginal 
operation  was  not  compassed  by  an  empty  demand  for  some- 
thing ideal. 

It  is  clear  that  a  radical  operation  is  of  double  importance 
for  exactly  those  cases  having  the  gravest  symptoms  and 
pathological  changes ;  after  an  incomplete  extirpation,  or 
hysterectomy  alone,  the  elements  likely  to  disturb  the  course 
of  recovery  can  develop  all  the  more  easily. 

One  cannot  deny  that  in  some  isolated  cases  any  further 
procedure  than  the  removal  of  the  uterus,  the  abdominal 
radical  operation  included,  simply  means  death  to  the  patient. 
Still,  as  a  rule,  with  a  suitable  technique  it  is  possible  to 
bring  down  and  extirpate  along  with  the  uterus  even  the 
most  extensively  diseased  appendages.  Two  years  ago,  in 
describing  the  method,  we  reported  an  extensive  series  of 
cases,  and  demonstrated  the  corresponding  specimens.1  In 
this  way  the  possibility  of  the  radical  procedure  in  the 
simple  as  well  as  in  the  grave  cases  has  been  theoretically 
established,  and  a  large  number  of  operations  by  others 
besides  ourselves  has  furnished  sufficient  practical  evidence. 
Against  these  facts,  will  the  objection  hold  good  that  the 
extirpation  of  severely-diseased  adnexa  is  only  possible  by 
the  abdominal  route,  and  that  their  removal  per  vaginam 
must  always  be  incomplete  ? 

We  wish  here  to  call  attention  to  the  fact  that  we  have 
repeatedly  published  the  results  of  our  method,  including  a 
series  of  demonstrations  of  the  operation,  of  the  preparations 
so  obtained,  and  an  accurate  history  of  the  patients.  Our 
reason  for  referring  to  this  is  that  Doyen,  who  upholds  the 
same  principle  of  total  extirpation,  has  made  no  detailed 
report  of  his  cases ;  hence  a  comparison  of  his  cases  with 
ours  in  the  above  manner  is  not  possible.  Doyen,  among  his 
first  series  (seventy-seven  cases)  was  often  obliged  to  leave 
1  L.  Landau,  Congress  of  the  Germ.  Gyn.  Soc.,  Vienna,  1895. 


30  THE  VAGINAL  RADICAL  OPERATION 

portions  of  the  adnexa  behind,  and  in  four  cases  portions  of 
the  uterus  as  well.1  Segond  also  acknowledges  that,  up  to 
the  time  of  his  employment  of  the  method  of  morcellement, 
he  also  was  occasionally  compelled  to  leave  fragments  of  the 
uterus  within  the  patient's  abdomen. 

For  our  part,  we  consider  the  entire  removal  of  the  womb 
possible  in  every  case.  The  motive  for  Pean's  and  Segond's 
self-imposed  limitation  of  the  operation  in  grave  suppurative 
cases,  to  a  mere  extirpation  of  the  uterus,  is  certainly  to  be 
found  in  their  own  technique,  which  demands,  among  other 
things,  that  nothing  be  undertaken  except  under  direct  visual 
control. 

Contrary  to  this,  we  designed  and  still  practise  puncture 
and  enucleation  by  palpation,  as  well  as  the  removal  of  the 
adnexa  in  the  same  way,  and  consider  it  indispensable  for 
the  radical  procedure.  In  this  way  (palpatory  enucleation) 
it  is  surprisingly  easy  to  remove  the  appendages,  even  when 
enormously  enlarged. 

Those  who  on  theoretical  grounds  assert  that  such  a 
procedure  is  contrary  to  good  surgical  principles  need  only 
consider  a  parallel  case — for  instance,  ventral  laparotomy  for 
pus-tubes  or  ovarian  abscesses  adherent  deeply  in  the  pelvis. 
Here,  in  spite  of  all  Trendelenberg  positions,  these  organs 
or  tissues  must  be  removed  blindly,  i.e.,  wholly  by  touch. 
And  will  it  occur  to  somebody  else  to  reject  version  or  the 
obstetrical  forceps  simply  because  the  parts  that  are  so 
manipulated  are  invisible  ? 

In  the  endeavour  to  remove  all  the  diseased  tissue,  we 
were  justified  by  the  leading  principles  and  the  details  of  our 
technique,  which  is  materially  different  from  that  of  Pean 
and  Segond.  Since  1887,  in  all  our  hysterectomies  for 
carcinoma,  the  complete  freeing  of  the  diseased  organ  has 
methodically  preceded  the  arrest  of  haemorrhage,  and  this 
fundamental  principle  of  the  technique  was  brought  into  the 
vaginal  radical  operation.  Thus,  the  order  of  procedure  is  : 
First  of  all  enucleation  of  everything  that  is  to  be  extirpated, 
then  formation  of  the  pedicle,  and  finally  hsemostasis  im- 
mediately before  the  excision  and  the  end  of  the  opera- 
1  Doyen,  Internal.  Gynec.  Cong.,  Brussels,  1892. 


TECHNIQUE  OF  THE  OPERATION  31 

tion.     Doyen,  independently  of  us,  has  also  advocated  this 
principle.1 

This  modification  of  Pean's  technique  is  not  the  result  of 
an  innovation  mania  with  us,  but  is  of  absolute,  intrinsic 
value  to  the  operation.  Experience  has  taught  that  every 
clamp  employed  is  to  a  certain  extent  a  hindrance  to  the 
operator,  and  in  unskilled  hands  traction  on  these  instru- 
ments may  cause  haemorrhage  and  undesirable  laceration. 
With  a  number  of  clamps  in  use  during  the  operation,  the 
space  for  fingers  and  instruments  in  freeing  the  internal 
genitalia  is  very  unpleasantly  limited,  especially  in  case  of 
a  small  narrow  vagina.  Further,  these  forceps  in  place 
before  the  organs  are  resected  are  more  or  less  an  obstacle 
to  the  convenient  formation  of  the  pedicles,  for  by  their  use 
one  gets  a  variable  number  of  small  stalks  instead  of  a  large 
and  firm  pedicle  which  could  have  been  had  by  dispensing 
with  them  until  everything  had  been  properly  liberated. 
What  could  well  have  been  brought  into  one  mass,  easy  of 
supervision  and  convenient  for  traction  toward  the  vagina, 
is  divided  up  into  many  parts. 

Therefore  every  clamp  applied  prior  to  the  freeing  of  the 
organs  hinders  complete  extirpation  ;  the  areas  marked  off 
by  the  haemostatic  forceps  limit  the  field  of  the  operation. 
Undeniably  Pean  and  Segond's  technique,  in  which  the  control 
of  the  haemorrhage  plays  the  chief  part,  suffices  for  the 
removal  of  the  uterus ;  but  it  is  equally  certain  that  it 
presents  greater  difficulties  in  the  execution  of  the  vaginal 
radical  operation.  We  acknowledge  this  all  the  more  readily, 
for,  according  to  our  own  experiences,  there  are  occasional 
instances  in  which,  before  the  adnexa  can  be  resected,  nothing 
else  than  Pean's  method  is  possible — total  extirpation  or 
morcellement  with  preventive  clamping.  Segond,  feeling 
that  this  prophylactic  use  of  the  clamps  was  a  hindrance, 
has  emancipated  his  own  method  also  from  the  strictly 
bloodless  operation.  However,  he  advanced  only  half  a 
step,  for  he  still  secures  the  uterine  arteries  before  com- 
mencing the  excision  of  the  womb.  And  when  Pean  and 
his  school  recommended  the  simple  removal  of  the  uterus 
1  Landau  and  Doyen,  Twenty-fourth  Congress  of  German  Surgeons,  1895. 


32  THE  VAGINAL  RADICAL  OPERATION 

for  all  the  forms  of  pelvic  suppuration,  it  would  seem  that 
this  limitation,  with  which  they  were  satisfied,  was  the  direct 
result  of  their  chosen  prophylactic  method. 

We  have,  on  the  contrary,  dispensed  with  all  primary 
hgemostasis ;  our  chief  aim  is  to  first  liberate  all  the  struc- 
tures involved,  bring  them  down  into  sight,  and  form  a 
pedicle.  Haemostasis  is  the  last  and  the  closing  act  of  the 
operation ;  with  Pean  it  is  the  chief  care,  ever  recurring 
throughout  the  whole  operation.  This  endeavour  on  our 
part  causes  our  method  to  very  materially  differ  practically 
from  that  of  the  original  Pean's  operation,  in  spite  of  our  use 
of  his  clamps. 

In  order  to  illustrate  the  development  of  the  method,  we 
may  briefly  review  the  chief  points  in  the  treatment  of 
diseases  of  the  adnexa  as  practised  in  our  clinic  : 

Differential  classification  of  pelvic  suppuration  ;  accurate 
diagnosis,  assisted  when  necessary  by  exploratory  puncture 
to  establish  the  purulent  nature  of  the  so-called  parametric 
indurations ;  the  treatment  of  each  case  on  its  merits, 
vaginal  or  abdominal  incision  ;  vaginal  or  abdominal  extir- 
pation of  diseased  appendages,  or  the  vaginal  radical  opera- 
tion—  the  first  procedure  always  when  the  trouble  is 
unilateral,  the  latter  always  in  case  of  bilateral  disease. 
The  vaginal  radical  operation  also  in  bilateral  non-suppura- 
tive  affections ;  as  well  as  for  the  severest  cases,  com- 
plicated pelvic  abscesses,  in  some  instances  with  the  aid 
of  ventral  laparotomy.  In  the  technique  :  introduction  of 
the  palpatory  enucleation,  primary  liberation  of  all  the 
tissues,  and  pedicle  formation,  hsemostasis  being  secondary. 
Prophylactic  hsemostasis  in  the  sense  of  Pean's  operation 
only  as  a  method  of  necessity. 


CHAPTER  V. 

THE    VAGINAL    RADICAL   OPERATION    IN    A    BROADER    SENSE. 

FOR  the  vaginal  extirpation  of  myomatous  uteri  we  employ 
the  same  principles  of  technique  ;  but  here,  of  course,  among 
the  other  manipulations,  Pean's  morcellement  holds  the  chief 


THE  OPERATION  IN  A   BROADER  SENSE  33 

place.  As  is  well  known,  this  operator  and  Urdy  devised  the 
method  as  early  as  1873  for  the  abdominal  extirpation  of 
myomata.  Pean  employed  it  for  tumours  of  other  organs  as 
well,  but  especially  in  vaginal  myomo-hysterectomy,  vaginal 
hysterectomy,  and  hystero-myomectomy. 

We  have  tried  this  method  in  a  large  number  of  fibroids, 
some  reaching  to  the  umbilicus,  and  with  excellent  results. 
In  the  last  few  years  we  have  had  equally  good  results  with 
other  methods,  namely,  the  combined  abdomino  -  vaginal 
operation,  lately  described  by  L.  Landau,  and  Doyen's 
brilliant  and  astonishingly  simple  abdominal  extirpation. 
Still,  in  selecting  a  method  of  removing  a  myomatous  uterus, 
as  far  as  it  is  a  matter  of  choice,  we  should  always  seek  first 
for  contra-indication  to  the  vaginal  procedure,  rather  than 
for  indications  for  laparotomy.  We  take  this  stand  because 
in  general  we  prefer  every  vaginal  operation  to  the  abdominal 
or  the  combined  methods,  and  naturally  with  the  presump- 
tion that  a  greater  number  of  operations  will  demonstrate 
the  greater  worth  of  the  vaginal  procedure. 

The  chief  technical  principles  involved  in  the  vaginal  radical 
operation  for  diseases  of  the  appendages,  and  in  vaginal 
hysterectomy  for  myoma  or  cancer  of  the  womb,  are  all  so  in 
accord,  and  uterine  and  adnexal  disease  are  so  often  com- 
bined, that  we  are  prompted  to  include  in  the  term  '  vaginal 
radical  operation  '  all  vaginal  hysterectomies  undertaken 
for  the  above-named  indications.  In  the  removal  of  the 
uterus  per  vaginam  for  prolapse,  uncontrollable  haemorrhage, 
carcinoma  or  myoma,  vaginal  hysterectomy  can,  in  case  of 
normal  appendages,  and  should,  if  the  latter  are  diseased,  take 
the  form  of  the  vaginal  radical  operation. 

So  the  list  of  indications  is  increased  ;  but  in  spite  of  their 
variety,  the  technique  of  the  operation  remains,  as  a  whole, 
the  same,  with  minor  variations  and  subdivisions. 

The  following  description  of  the  technique  is -based  upon 
an  experience  of  nearly  500  cases  so  treated. 


PART  II. 

TECHNIQUE  OF  THE  VAGINAL  RADICAL  OPERATION. 


A.— GENERAL   CONSIDERATIONS. 

WHEN,  for  a  number  of  different  conditions,  the  operative 
procedure  required  is  in  all  essential  points  the  same,  it 
follows  that  certain  surgical  principles  of  general  applicability 
will  recur  and  be  made  use  of  in  each  individual  operation. 
The  opponents  of  the  operation  in  question  have  attacked 
every  single  point  of  the  method,  always  with  reference  to 
general  '  surgical '  principles,  apparently  forgetting  that  a 
great  many  modern  views,  once  accepted  as  finite  surgical 
dogmas,  have  nevertheless  been  changed  in  the  course  of 
time. 

On  these  grounds  it  seems  to  us  necessary,  before  passing 
on  to  the  special  description  of  the  technique  of  the  vaginal 
radical  operation,  to  make  some  observations  which  will 
demonstrate  in  a  general  way  the  main  principles  of  our 
procedure,  and  test  the  value  of  the  objections  advanced  by 
its  opponents. 

CHAPTER  I. 

OUR  OPERATION  :  THE  ENUCLEATING  PROCEDURE THE  SO- 
CALLED  CLAMP  METHOD — QUALITIES  AND  ADVANTAGES 
OF  THE  CLAMPS. 

NOTHING  has  hindered  the  proper  understanding  of  our 
vaginal  extirpation  of  the  internal  genitalia  more  than  the 
common  term  '  clamp  operation.'  Pean's  clamp  method 

3—2 


36  THE  VAGINAL  RADICAL  OPERATION 

did,  indeed,  suggest  the  way  along  which  our  procedure  was 
developed,  but  our  technique  is  not  that  of  the  clamp  opera- 
tion, and  cannot  properly  be  described  by  this  term.  The 
first  step  in  Pean's  work  of  reform  consisted  in  this,  that  he 
taught  the  use  of  the  clamps  instead  of  the  ligature  as  a 
means  of  controlling  uterine  haemorrhage.  Herein  lay  the 
difference  between  his  and  the  other  methods  of  hysterectomy, 
and  this  circumstance  made  his  operation  the  clamp  method 
par  excellence, 

This  is  the  proper  designation  of  those  methods  of  extir- 
pation in  which  the  clamps  are  employed  from  necessity — 
that  is,  in  operating  on  large  immobile  uteri  which  do  not 
respond  to  any  downward  traction.  But  apart  from  this, 
our  use  of  the  clamps  is  of  a  secondary  consideration  ;  in 
fact,  our  procedure  is  entirely  different  from  the  original 
Pean's  method. 

For  Pean  and  his  school,  throughout  the  whole  operation, 
the  control  of  the  haemorrhage,  the  '  preventive  hsemostasis  ' 
is  of  chief  importance ;  for  us  the  complete  freeing  and 
isolation  of  all  the  structures  to  be  extirpated  is  of  chief 
moment,  even  to  the  neglect  of  the  vessels.  With  Pean 
the  haemostasis  is,  with  reference  to  the  enucleation,  preven- 
tive or  primary  ;  with  us  it  is  consecutive — that  is,  secondary.1 

Thus,  if  Pean's  operation  be  designated  as  the  clamp 
method  on  account  of  the  chief  principle  involved,  so  must 
our  operation  with  reference  to  its  fundamental  principles  be 
called  the  extraction,  or,  better,  the  enucleation  method. 

In  our  operation,  after  the  essential  principle  has  been 
carried  out,  i.e.,  after  the  organs  or  tissues  have  been  freed 
from  adhesions,  enucleated  and  pediculated,  as  far  as  the 

1  There  is  a  great  deal  of  confusion  among  the  different  writers  in  regard 
to  the  names  of  the  various  kinds  of  haemostasis  used  in  such  operations  ; 
the  terms  '  preventive,  temporary,  provisional,'  and  '  definite,  consecutive,' 
are  employed  very  inaccurately. 

By  '  provisional '  or  'temporary'  is  meant  any  haemostatic  means  which 
is  replaced  by  some  other  agent,  or  removed  entirely  in  the  course  of  the 
operation.  The  opposite  is  '  definite.' 

That  form  of  haemostasis,  like  Plan's,  which  precedes  the  enucleation 
is  to  be  called  'preventive'  or  'primary.'  When  it  follows  the  enuclea- 
tion, as  in  our  method,  it  is  '  consecutive '  or  '  secondary.' 


THE  ENUCLEATION  METHOD  37 

haemostasis  alone  is  concerned,  the  ligature  or  clamp  may  be 
used  at  will.  But  when  we  say  that  we  choose  the  clamp 
instead  of  the  ligature  in  every  case,  this  preference  is  based 
upon  advantages  far  beyond  the  use  of  these  instruments 
merely  as  a  haemostatic  means.1 

Most  certainly  they  shorten  the  operation ;  they  spare  the 
patient  (often  weakened  by  preceding  haemorrhage)  the  un- 
necessary loss  of  blood,  and  favourably  shorten  the  duration 
of  the  anaesthesia.  Further,  in  certain  stages  of  the  opera- 
tion, the  clamps  rightly  placed  may  be  useful  as  retractors 
in  exposing  the  field  of  operation,  and  offer  a  good  handle 
for  the  examination  of  the  pedicles.  This  latter  procedure 
is  unsafe  when  the  ligature  is  used,  because  of  the  possible 
slipping  of  the  ligature,  and  resulting  haemorrhage.  More- 
over, the  weight  of  these  instruments  draws  the  stumps 
down  and  maintains  them  in  the  vagina  in  a  position  which 
not  only  offers  the  conditions  requisite  for  extra-peritoneal 
healing,  but  directly  assists  in  the  process.  This  point  will 
be  discussed  later  on. 

The  clamps  serve  also  for  drainage,  preventing  like  a  glass 
or  rubber  tube  the  primary  adhesion  of  the  wounded  edges, 
and  form  an  excellent  framework  for  the  absorbent  gauze, 
which,  supported  by  them  and  protected  from  compression 
and  adhesion,  develops  its  full  power  of  drainage. 

While  the  drainage  of  non-inflammatory  cases  (myomata) 
is  a  matter  of  choice,  it  is  certainly  necessary  in  all  inflam- 
matory and  suppurative  processes,  especially  where  portions 
of  intra-  or  extra-peritoneal  abscesses,  fused  to  the  gut  or 
bladder  wall,  must  be  left  behind.  It  is  also  necessary  in 
purulent  carcinomata. 

For  these  latter  cases  an  especially  important  aid  to  the 
success  of  the  operation  is  the  crushing  and  necrotizing 
effect  of  the  clamps  upon  the  tissue  grasped  by  them. 

1  The  only  exception  to  this  rule  is  in  hysterectomy  for  procidentia. 
When  in  such  cases  the  operation  is  indicated,  we  prefer  the  ligature  to 
the  clamps  ;  after  completing  the  resection  of  the  uterus  and  superfluous 
vaginal  wall,  we  close  the  vaginal  vault  with  a  purse- string  suture.  Where, 
however,  the  prolapse  is  complicated  with  inflammatory  or  suppurative 
processes,  (salpingitis,  pyosalpinx,  pelvic  abscess),  the  clamps  must  be 
used  instead  of  the  ligature. 


38  THE  VAGINAL  RADICAL  OPERATION 

Germs  lying  in  the  blood  and  lymph  vessels  in  parts  only 
microscopically  affected  are  annihilated  by  the  pressure. 
To  destroy  the  adjacent  tissues  as  widely  as  possible,  the 
ideal  method  would  be  to  use  some  other  necrosis-producing 
agent  (thermo-cautery)  to  those  parts  of  the  field  of  operation 
which  cannot  be  enclosed  within  the  forceps — for  instance, 
upon  the  posterior  bladder  wall,  or  the  anterior  surface  of 
the  rectum  ;  but,  unfortunately,  an  extensive,  even  if  super- 
ficial, cauterization  cannot  here  be  made  without  grave 
danger  to  the  patient  from  necrosis  of  these  organs  due  to 
multiple  thrombosis.  Otherwise  the  thermo-cautery  is  of  no 
advantage.  To  burn  the  ligaments  inside  the  clamps,  and 
then  remove  these  latter,  seems  inconsistent ;  it  is  better  to 
leave  the  clamps  in  place,  and  let  them  destroy  the  tissue  by 
pressure,  which  they  will  certainly  do  for  at  least  their  own 
breadth.  On  the  other  hand,  when  the  ligaments  are 
severed  by  the  cautery,  and  the  clamps  left  in  place,  the 
cautery  has  merely  performed  the  service  of  any  cutting 
instrument,  such  as  the  knife  or  scissors. 

Further,  it  seems  to  us  quite  possible  that,  in  the  ligature 
operation  upon  a  cancerous  uterus,  the  needle  in  trans- 
fixing the  ligament  may  carry  germs  from  diseased  into 
healthy  tissue. 

As  we  see,  the  clamp  method  is,  after  all,  something  more 
than  a  special  form  of  haemostasis  ;  it  possesses  besides  this 
other  qualities  which  recommend  its  use  :  drainage,  extra- 
peritoneal  wound-healing,  etc.  These  properties  are  of  such 
a  decided  advantage  over  the  ligature  method  that,  even  in 
the  cases  where  it  is  easy  to  control  the  haemorrhage  by 
ligation,  we  discard  it  in  favour  of  the  clamps.  Although, 
as  before  stated,  in  certain  stages  of  our  operation  the 
ligature  may  be  employed  in  the  technique,  it  must  not 
be  inferred  that  wre  were  contemplating  a  return  to  the  old 
and  commonly  used  ligature  method.  Our  operation  is  neither 
the  clamp  nor  the  ligature  method,  but  is  an  enucleation  procedure, 
a  method  which  proposes  the  liberation  of  the  internal  geni- 
talia  in  one  mass,  and  which  is  concluded  by  the  use  of  ford- 
pressure  instead  of  ligation,  which,  as  far  as  haemostasis  is 
concerned,  is  just  as  practicable. 


ADVANTAGES  OF  THE  CLAMPS  39 

In  the  small  number  of  cases  in  which  the  enucleation 
process  is  not  practicable,  the  usual  ligature  method  is  quite 
impossible.  Here  the  '  clamp  method '  is  the  operation  of 
necessity,  solely  on  account  of  the  haemostasis,  and  here  it 
is  a  quite  indispensable  factor  to  the  success  of  the  operation. 
Such  are  the  cases  in  which  the  uterus  is  directly  or  indirectly 
fixed  and  immobilized  by  its  size,  by  adhesions,  or  by  changes 
in  the  adnexa,  and  the  areas  in  which  the  haemorrhage  must 
be  controlled  can  in  no  way  be  made  mobile.  When,  in 
these  cases,  the  old  vaginal  methods  of  operation  are  tried, 
although  some  assistance  may  be  derived  from  auxiliary 
operations,  such  as  perineal  section,  sacral  and  parasacral 
incision  and  resection,  the  procedure  is  bloody,  demands 
a  great  deal  of  time,  and  is  often  impracticable.  The  blood- 
vessels are  high  up,  and  to  reach  and  ligature  them  is  a 
matter  of  the  greatest  difficulty.  The  most  zealous  champions 
of  the  ligature  method  are  often  obliged  to  employ  the  clamps 
in  such  cases,  and  leave  them  on  from  necessity. 

We  acknowledge  that,  in  some  cases  of  the  above  sort, 
uteri  with  large  myomata,  or  with  bilateral  inflammatory 
changes  in  the  adnexa,  may  be  removed  per  vaginam  by  the 
ligature  method,  but  not  without  difficulty.  But  those  cases 
which  most  of  all  demand  a  radical  operation  are  precisely 
the  ones  which  are  in  general  excluded  from  the  possibility 
of  vaginal  removal,  unless  the  advantages  offered  by  the 
clamp  method  are  made  use  of.  Such  are  large  uteri  walled 
in  by  inflammatory  products,  enormous  pus-tubes  with  intra- 
and  extra-peritoneal  abscesses,  complicated  pelvic  suppura- 
tion ;  these  are  cases  in  which  the  organs  fixed  high  up  in  the 
pelvis  can  be  extirpated  by  aid  of  the  clamps,  with  certain 
control  of  the  haemorrhage. 

Thus,  in  this  category  the  ligature  may  be  of  service  in 
isolated  cases,  the  clamps  in  all,  without  exception.  Accord- 
ingly, the  proper  method  here  lies  in  the  use  of  the  clamps,  not  the 
ligature. 

If  in  this  description  of  the  clamp  method  we  have 
entered  somewhat  fully  into  details,  we  can  dispose  of  the 
objections  of  its  opponents  very  briefly,  and  mainly  with 
regard  to  two  points  : 


40  THE  VAGINAL  RADICAL  OPERATION 

First  by  the  simple  reference  to  our  results  obtained  in 
a  series  of  nearly  500  operations. 

Secondly,  it  is  a  striking  fact  that  all  the  objections  have 
been  brought  by  those  who  do  not  practise  the  method 
themselves,  or,  what  is  still  worse,  by  those  who  without 
proper  knowledge  of  the  technique,  or  without  a  suitable 
armamentarium,  have  tried  the  operation  once  or  a  few 
times,  to  the  injury  of  their  patients. 

Secondary  haemorrhage  and  injury  of  adjacent  organs  are 
certainly  not  more  frequent  with  the  clamp  method  than 
with  the  ligature.  The  further  objections — uncertain  control 
of  the  haemorrhage  during  the  operation,  danger  of  embolism 
from  excessive  thrombosis,  laceration  of  the  ligaments,  etc. — 
can  only  come  from  those  who  are  not  well  acquainted  with 
the  method.  That  some  gynaecologists  with  a  limited  ex- 
perience have  had  a  high  mortality  in  their  cases,  or,  as 
some  have  said,  only  fatal  cases,  with  the  clamp  operation, 
is  a  matter  which  it  is  difficult  for  us  to  explain.  But  their 
failures  cannot  be  allowed  to  put  in  question  the  excellent 
results  achieved  in  a  large  series  of  operations  by  other 
writers,  nor  to  detract  from  the  value  of  the  method,  any 
more  than  so  much  theoretical  discussion ;  for  facts  are 
stronger  than  theories. 


CHAPTER  II. 

NON-CLOSURE    OF    THE    ABDOMINAL    CAVITY — MECHANISM    OF 
THE    HEALING. 

WE  shall  describe  in  further  detail  one  point  in  connection 
with  the  use  of  the  clamps :  not  because  it  might  serve  those 
unacquainted  with  the  procedure  as  a  leading  argument 
against  the  clamp  method,  but  because  it  forms  one  of  its 
important  and  useful  features ;  namely,  the  closure  of  the 
peritoneal  cavity.  This,  in  the  ligature  method,  is  completed 
by  suturing,  for  fear  of  infection  of  the  peritoneum ;  but  in 
the  clamp  operation  it  must  be  left  out. 

This  is  what  we  consider  an  especial  advantage  of  the 
clamps,  one  that  is  chiefly  brought  into  play  in  the  operation 


MECHANISM  OF  HEALING  OF  THE  PERITONEUM       41 

for  inflammatory  purulent  or  ichorous  affections  of  the  uterus 
and  appendages. 

Indeed,  so  little  do  we  regard  the  non-closure  of  the  peri- 
toneum as  a  weak  point  of  the  clamp  method,  that  we  do 
not  shut  off  the  abdominal  cavity  from  the  dangerous  vagina 
even  in  cases  where  we  employ  Doyen's  ingenious  abdominal 
hystero-myomectomy  with  the  ligature.  The  favourable  and 
possibly  astonishing  results  of  this  intentional  neglect  are 
due  to  the  fact  that  the  peritoneum  closes  itself  in  the  most 
effective  manner,  and  that  rapidly  and  in  the  best  position. 

With  the  ligated  inflamed  stumps  sewed  into  the  wound, 
resting  upon  the  peritoneum,  and  remaining  in  contact  with 
it  during  the  entire  process  of  healing,  an  ideal  extra-peri- 
toneal arrangement  is  difficult  to  achieve.  With  the  use  of 
the  clamps,  however,  the  healing  process  takes  an  entirely 
different  course. 

By  the  weight  and  traction  of  the  clamps  all  the  stumps, 
even  the  uppermost  portions  in  the  region  of  the  infundibulo- 
pelvic  ligament,  are  inverted  into  the  vagina,  and  the  pedicles 
lie  not  only  extra-peritoneal  but  intra-vaginal,  similar  to  the 
disposition  of  the  pedicle  after  ovariotomy,  where  the  clamp 
was  formerly  used,  although  in  a  much  more  reasonable 
position.  This  position  is  a  permanent  one,  for  the  traction 
of  the  clamps  during  at  least  twenty-four  hours  changes  the 
elasticity  of  the  tissue  so  that  the  stumps  do  not  retract 
again  into  the  intra-peritoneal  region  even  when  the  infun- 
dibulo-pelvic  ligament  is  included. 

The  gauze  covering  the  entire  wound  surface,  and  extend- 
ing beyond  the  points  of  the  forceps,  powerfully  excites  the 
rapid  formation  around  it  of  peritoneal  adhesions,  and,  as  it 
remains  there  for  several  days,  it  further  assists  the  plastic 
tendency  of  the  peritoneum.  The  peritoneal  sac  is  thereby 
rapidly  closed,  the  wound  cavity  becomes  transferred  from 
its  original  situation  into  the  vagina ;  hence  the  new  closure 
of  the  peritoneum  lies  in  the  proper  position,  i.e.,  above  the 
level  of  this  self-cleansing  wound.  When  we  consider,  in 
addition,  the  drainage  effect  of  the  clamps  and  gauze,  and 
the  fact  that  the  discharges  and  necrotic  products  have  a 
natural  and  safe  outlet  through  the  vagina,  we  see  that  all 


42  THE  VAGINAL  RADICAL  OPERATION 

the  necessary  conditions  for  the  open -wound  treatment, 
which  alone  is  suitable  for  inflammatory  and  suppurative 
processes,  are  amply  provided  for,  and  that  the  most  effective 
protection  against  retention  and  sepsis  is  secured.  By  the 
use  of  the  clamps  and  the  gauze  drainage,  this  self-protection 
of  the  peritoneum  is  so  complete  that  the  after-treatment  is 
reduced  practically  to  nil.  The  vaginal  douche  with  some 
bland  solution,  which  we  employ  first  on  the  sixth  day,  is 
chiefly  for  the  mechanical  removal  of  shreds  of  tissue  and 
secretions. 

The  non-closure  of  the  peritoneal  wound  offers  also  a 
ready  means  for  the  recognition  of  any  secondary  haemor- 
rhage which  may  occur  from  the  stumps,  an  advantage  not 
to  be  lightly  esteemed.  Bleeding  at  any  time  after  the 
operation  manifests  itself  at  once  outwardly,  whilst  after 
closing  the  abdominal  cavity,  a  fatal  haemorrhage,  from 
portions  of  the  stumps  which  have  slipped  out  of  the 
ligature,  may  occur  in  a  most  insidious  manner. 

The  results  achieved  in  spite  of  the  non-closure  of  the 
peritoneum  and  the  negative  after-treatment,  even  with  the 
most  extensive  suppurative  affections,  might  suggest  the 
thought  that  we  have  always  had  to  deal  with  sterile  pus  or 
with  non-virulent  inflammatory  agents.  The  best  answer  to 
this  is  that  a  large  number  of  the  cases  had  a  septic  tem- 
perature before  or  at  the  time  of  the  operation ;  several 
times  also  those  participating  in  the  operation  had  to  bear 
evidence  on  their  hands  of  the  virulence  of  the  pus.  To 
this  is  to  be  added  the  experience  that  in  some  purulent 
cases  where  laparotomy  had  to  be  combined  with  the  vaginal 
operation,  here  and  there,  in  spite  of  all  precautions,  abscesses 
occurred  in  the  abdominal  wound.  This  human  inoculation 
is  certainly  not  less  important  as  a  proof  of  pyogenic  viru- 
lence than  tube-culture  or  animal  inoculation. 

While  the  open  treatment  ensures  an  excellent  self- 
protection  of  the  wound  against  infectious  bacteria  after 
the  operation,  the  method  limits  the  danger  of  infection  of 
the  adjacent  tissues,  especially  the  peritoneum,  during  the 
operation,  and  this  without  special  irrigation  or  disinfection. 
For  in  every  part  of  the  operation  we  are  governed  by  the 


MECHANISM  OF  HEALING  OF  THE  PERITONEUM      43 

principle  of  non-interference  with  the  peritoneum,  which 
overlies  the  wound  in  two  broad,  loose  flaps  in  front  and 
behind.  Purulent  and  decomposing  fluids  escape  through 
the  vagina  at  once,  and,  what  is  most  important,  all  wound 
surfaces  which  might  serve  for  the  inoculation  or  diffusion  of 
pyogenic  bacteria  are  mechanically  shut  off  from  the  general 
circulation  in  a  certain  and  safe  manner.  Even  if  a  large 
number  of  lymph  and  blood  vessels  are  opened  during  the 
extirpation,  these  points  which  might  be  directly  inoculated 
by  the  septic  material  present  are  at  once  rendered  devoid 
of  danger  by  no  other  agent  than  the  compression  forceps, 
which  grasp  and  crush  the  whole  breadth  of  the  ligaments. 
The  ligature  whose  only  purpose  is  to  control  the  haemor- 
rhage could  only  have  this  crushing  effect  in  the  very 
isolated  cases  in  which  the  whole  ligament  is  tied  off  in  one 
mass.  This  protective  effect  of  the  clamps  on  the  tissues 
remains  operative  long  after  the  forceps  are  taken  off. 

The  large  lymph  channels  which  accompany  the  uterine 
arteries  in  the  '  cardinal  ligaments  '  (Kocks),  and  pass  by  the 
side  of  the  cervix,  are,  together  with  those  in  the  round 
ligament  and  in  the  upper  part  of  the  broad  ligament,  all 
grasped  and  crushed  by  the  clamps.  The  only  part  not 
secured  by  the  forceps  is  the  cellular  tissue  in  front,  and  in 
some  cases  that  behind  the  cervix.  From  the  absence  of 
suppurative  or  phlegmonous  inflammation  extending  from 
here  behind  the  peritoneum,  or  in  front  into  the  cavum 
Retzii,  one  must  conclude  that  these  tissues  have  but  little 
tendency  to  the  development  of  secondary  infection.  Thus, 
in  spite  of  the  presence  of  virulent  bacteria,  the  technique  of 
our  vaginal  extirpation  offers  no  opportunity  for  local  or 
general  infection  either  during  or  after  the  operation. 

It  only  remains  for  us  to  consider  in  a  few  words  the 
anatomical  changes  occurring  in  the  self-closure  of  the 
peritoneum.  In  this  matter  we  must  be  guided  chiefly  by 
theoretical  principles,  for  we  have  had  no  fatal  cases  that 
could  furnish  any  definite  information  on  this  point.  The 
process  of  healing  consists  mainly  in  the  formation  of 
adhesions  by  omentum  and  the  intestinal  serosa  round 
about  the  gauze,  or  in  the  coalescence  of  the  peritoneal  flap 


44  THE  VAGINAL  RADICAL  OPERATION 

loosened  from  the  front  of  the  uterus  with  the  serosa  of  the 
rectum. 

From  the  observation  of  our  patients  for  many  years,  we 
maintain  that,  in  spite  of  the  probable  frequency  of  the  first 
method  of  healing,  dangerous,  or  even  unpleasant,  intestinal 
disturbances  do  not  result.  Most  likely  the  newly-formed 
adhesions  are  soon  stretched  or  separated  by  the  peristaltic 
motion  of  the  intestines,  which  are  very  much  less  disturbed 
by  the  vaginal  than  by  the  abdominal  operations. 

We  do  not  believe  in  the  theory  that  the  closure  of  the 
peritoneum  takes  place  through  the  primary  union  of  the 
surfaces  of  the  broad  ligaments,  which  are  drawn  down 
funnel-wise  into  the  vagina  by  the  clamps.  The  only  por- 
tions of  these  structures  which  lie  in  contact  are  their 
central  parts,  clamped  and  necrotic. 

The  definite  closure  of  the  wound  in  the  vaginal  vault 
beneath  the  long-since-healed  peritoneum  is  a  typical  union 
by  secondary  intention,  favoured  by  the  succulence  and 
thickness  of  the  paracervical  tissues. 

The  fear  that  the  non-closure  of  the  abdomen  might  allow 
the  intestine  to  become  prolapsed  and  strangulated,  espe- 
cially during  the  vomiting  after  the  operation,  is  answered 
by  the  fact  that  we  have  observed  this  form  of  strangulation 
in  only  one  case  out  of  all  our  operations.  This  was  a 
patient  who,  on  the  fourth  night  after  the  operation,  got  up 
without  the  nurse  knowing  it,  and  walked  about  the  room ; 
the  result  was  intestinal  prolapse,  obstruction,  and  death. 
The  method,  however,  cannot  be  blamed  for  this  death. 

The  absence  of  intestinal  prolapse  may  be  explained  by 
the  shortness  of  the  mesentery,  which  allows  the  gut  only  a 
limited  excursion  towards  the  pelvic  outlet ;  besides  this,  the 
protrusion  is  hindered  by  the  anterior  vaginal  wall,  which, 
together  with  its  peritoneal  flap,  is  pushed  upward  by  the 
gauze  beyond  the  clamp  points,  forming  a  smooth  and  firm 
protective  pad. 


MORCELLEMENT  45 


CHAPTER  III. 

MORCELLEMENT. 

IN  a  certain  number  of  cases  the  ligature  method  is  un- 
availing, and  the  clamps  must  be  used  to  bring  these  cases 
within  the  scope  of  the  vaginal  operation.  So  in  like 
manner  the  principle  of  dividing  up  the  mass  is  brought 
into  play  as  a  second  effective  remedy — morcellement  in  the 
full  sense  of  the  word. 

This  procedure  is  employed  wherever  it  is  impossible 
to  deliver  the  structures  entire ;  it  must  always  be  done 
under  full  visual  control.  Its  purpose  and  aim  is  either 
to  diminish  the  organ  by  partial  dissection  until  it  can  be 
removed  through  the  vagina,  or,  by  cutting  away  portions 
of  the  mass,  to  make  room  for  its  enucleation  and  extir- 
pation through  the  space  so  gained.  These  morcellating 
procedures  are  chiefly  auxiliary  ;  they  become  independent 
operations  only  when  it  is  necessary  to  extirpate  the  whole 
organ  in  this  way.  So  far  as  a  radical  operation  is  con- 
cerned, this  method  is  required  for  the  uterus  in  the  first 
place  for  fibroids,  and  in  the  second  place  for  grave  inflam- 
matory or  suppurative  adnexal  tumours,  when  the  uterus  is 
firmly  walled  in,  and  for  pelvic  peritonitis,  with  fixation  of 
the  organ. 

To  this  latter  group  belong  also  those  conditions  in  which 
it  is  impossible  to  deliver  the  uterus  as  a  whole  on  account 
of  the  brittleness  and  friability  of  its  parenchyma.  These 
are  chiefly  cases  of  puerperal  subinvolution,  complicated 
pelvic  abscesses  after  labour  or  abortion,  or  metritis  with 
severe  osdematous  or  cellular  infiltration. 

By  the  aid  of  morcellement,  therefore,  three  obstacles  are 
overcome  :  firstly,  enlargement  of  the  womb,  preventing  its 
delivery  through  the  pelvic  outlet ;  secondly,  direct  (peri- 
metritis)  or  indirect  (diseases  of  the  adnexa)  fixation,  which 
hinders  the  descent  of  the  organ  into  the  lower  plane  of  the 
pelvis,  and  thereby  obstructs  the  access  to  the  upper  portion 
of  the  uterus  and  the  appendages  ;  thirdly,  great  sponginess 
and  friability  of  the  uterine  tissue,  which  would  otherwise 


46  THE  VAGINAL  RADICAL  OPERATION 

prevent  extirpation.  Naturally,  the  difficulty  may  be  greatly 
augmented  when  one  has  to  deal  with  an  enormously  large 
uterus  directly  or  indirectly  fixed,  or  when  a  combination  of 
softening  with  fixation  is  met  with. 

A  matter  of  great  importance  in  all  these  procedures  is  in 
a  certain  sense  their  prophylactic  side.  They  permit  of  the 
extirpation  of  fixed  or  enlarged  uteri,  and  also  of  organs  in 
which  these  conditions  are  both  present  at  the  same  time, 
giving  the  operation  in  this  way  an  extension,  especially  with 
the  clamps,  far  beyond  the  limits  of  the  usual  Czerny 
method.  They  thereby  limit,  or  entirely  do  away  with,  the 
auxiliary  operations  which  supplement  the  latter  method, 
i.e.,  the  sacral  and  parasacral  methods,  Schuchardt's  opera- 
tion, laparotomy,  and  that  hoary  antiquity  the  perineo- 
vaginal  section. 

It  cannot  be  otherwise  than  beneficial  to  the  patient  when 
one  avoids  further  dangerous  and  mutilative  injury  to  other 
structures  when  doing  the  vaginal  extirpation.  Technically 
it  is  really  not  clear  why  one  should  unnecessarily  give  such 
operations  more  liberty  here,  in  contradistinction  to  the  general 
effort  to  avoid  neighbouring  injuries  wherever  possible. 

Those  who  like  striking  expressions  may  designate  the 
above  procedures  as  '  unsurgical.' 

As  an  aid  to  morcellement  in  case  of  uteri  indirectly  fixed 
by  serious  purulent  or  haemorrhagic  exudates  about  the 
adnexa  or  encapsulated  inside  or  outside  the  peritoneum, 
comes  the  evacuation  of  these  cysts  during  the  operation 
through  a  wide  opening  in  the  vagina. 


CHAPTER  IV. 

CLASSIFICATION,  MECHANISM  AND  METHOD  OF    PERFORMANCE 
OF    THE    MORCELLATING    OPERATIONS. 

WE  divide  these  operations  on  the  uterus  into  two  large  and 
distinct  groups  :  Section  of  the  organ,  and  piecemeal  extir- 
pation— '  morcellement '  in  the  true  sense. 

By  section  we  understand  the  methods  in  which  the  womb 


METHODS  OF  MORCELLEMENT  47 

is  opened  in  the  sagittal  line  through  one  or  both  walls — 
i.e.,  partial  or  complete  section.  In  the  latter  case  it  is,  of 
course,  divided  into  two  lateral  symmetrical  halves.  By 
morcellement  or  piecemeal  extirpation  we  mean  the  methods 
by  which  the  organ  is  dissected  and  cut  away  in  pieces. 
The  incisions  and  the  resulting  masses  may  show  a  certain 
symmetry,  or  they  may  be  entirely  irregular  and  asym- 
metrical ;  accordingly  there  is  to  be  distinguished  a  regular 
and  an  irregular  morcellement. 

As  above  stated,  the  principle  of  all  these  procedures  is  to 
make  room  by  freeing  or  extirpating  the  obstructing  parts, 
so  that  the  remainder  of  the  organ  may  be  enucleated  in  one 
mass,  and  its  pedicle  secured.  As  a  rule,  these  operations  are 
merely  auxiliary.  They  are  independent  procedures  only 
where,  in  spite  of  morcellation,  the  enucleation  of  the 
remaining  parts  is  not  possible  until  the  organ  has  been 
entirely  dissected  away ;  the  whole  operation  is  then  a  con- 
tinuous morcellement. 

A  uterus  immobilized  by  its  size  (myomata)  or  by  peri- 
metritic  adhesions  or  diseased  adnexa  is  broadened  out 
merely  by  splitting  the  anterior  or  posterior  wall  in  the 
median  line  ;  it  is  unrolled  like  a  cylinder  after  a  vertical  section, 
and  its  thickness  is  materially  diminished. 

Sagittal  incision  of  one  of  the  uterine  walls  is  often 
sufficient,  by  the  resulting  flattening  of  the  organ,  to  render 
mobile  a  womb  previously  fixed  by  its  size,  and  to  enable  it 
to  be  delivered  into  the  vagina  ;  or,  in  other  cases,  the  pelvic 
cavity  is  made  accessible  where  it  was  previously  closed  by 
the  enlarged  organ  like  a  cork  in  the  neck  of  a  bottle.  The 
unrolling,  which  follows  the  median  incision,  forms  a  breach, 
or  rather  a  canal,  through  which  one  or  two  fingers  may  be 
passed  over  the  fundus  into  the  true  pelvis,  and  parametritic 
adhesions  torn  away,  collections  of  fluid  evacuated,  or  the 
adherent  appendages  loosened.  If  the  fixation  is  chiefly  due 
to  inflammatory  products  about  the  tubes  and  ovaries,  which 
hold  the  uterus  by  traction  on  its  sides  and  upper  angles, 
the  incision  not  only  gives  more  space  through  the  unrolling 
and  flattening  of  the  organ,  but  it  also  renders  it  mobile  by 
lessening  the  strong  tension  upon  it.  The  traction  right  and 


THE  VAGINAL  RADICAL  OPERATION 


left  from  the  median  line  is  correspondingly  decreased  at 
every  point  on  the  uterus  after  the  wall  is  opened. 

It  is  evident  that  the  complete  median  division  of  the 
organ  must  have  at  least  double  the  benefit  of  the  simple 
incision  of  one  wall.  By  this  procedure,  which  comes  into 
play  chiefly  for  the  enucleation  of  fixed  and  gravely-diseased 
adnexa,  a  broad  gaping  space  is  formed  in  the  middle  as  a 
result  of  the  entire  abolition  of  this  traction  from  the 
sides. 

From  these  sectional  methods  those  which  we  designate 
as  piecemeal  extirpation  differ  only  in  degree,  not  in 
principle.  They  are  indicated  when  it  seems  impossible  to 
extirpate  the  organ  as  a  whole  with  or  without  the  sagittal 
incision,  or  when  this  fact  becomes  evident  during  the  opera- 
tion. Very  often  morcellement,  or  even  the  median  incision, 
is  of  great  advantage  as  a  method  of  choice,  since  the 
perineal  and  vaginal  incisions  are  avoided  thereby,  and  all 
the  structures  to  be  extirpated  can  be  brought  into  sight  one 
after  the  other.  Morcellement  is  a  necessity  when  bilateral 
tubal,  ovarian,  or  other  extra-  or  intra-peritoneal  abscesses 
are  present,  together  with  broad,  hard,  pelvi  -  peritonitic 
masses  which  quite  obliterate  the  pouch  of  Douglas,  and 
extend  solidly  to  the  pelvic  floor.  In  such  a  case  the  mere 
sagittal  section  would  be  entirely  insufficient,  for  the  right 
and  left  halves  of  the  immobilized  organ  do  not  retract 
laterally ;  they  are  \valled  in  by  these  masses  and  remain  in 
place,  an  obstacle  in  the  way  of  reaching  the  diseased  appen- 
dages. The  solid  direct  or  indirect  fixation  of  the  uterus, 
even  when  not  accompanied  by  enlargement,  often  necessi- 
tates its  extirpation  in  situ  by  means  of  morcellement. 

Morcellement  is  further  required  for  uteri  which,  sur- 
rounded by  encapsulated  abscesses,  have  become  abnormally 
friable  through  inflammatory  cedema,  softening,  and  cellular 
infiltration,  or  in  cases  where  the  softness  and  fragility 
are  due  to  puerperal  subinvolution.  In  such  cases  strong 
traction  on  the  volsellae  leads  at  once  to  laceration  and 
haemorrhages. 

Finally,  the  method  of  piecemeal  extirpation  is  forced 
upon  us  in  cases  where  the  womb,  previously  opened  or 


METHODS  OF  MORCELLEMENT  49 

halved,  cannot  pass  through  the  natural  obstetrical  outlet  ; 
for  instance,  cases  of  enlargement  caused  by  tumours,  more 
especially  fibroids.  Myomata  reaching  to  the  navel,  together 
with  the  uterus,  may  be  removed  through  the  vagina  by 
morcellement,  with  more  trouble  to  the  operator  than  danger 
to  the  patient. 

In  testing  the  mobility  of  the  uterus,  one  must  not  be  too 
easily  deceived  ;  sometimes  by  traction  on  the  portio  the 
organ  seems  to  descend  into  the  vagina,  merely  because  the 
elastic  cervical  tissue  is  put  on  a  stretch  and  yields  some- 
what, while  the  corpus,  fixed  by  its  size  or  by  adhesions, 
remains  in  place  unchanged. 

A  parallel  may  well  be  drawn  between  the  mechanism  of 
piecemeal  extirpation  and  certain  obstetrical  procedures.  In 
removing  a  dead  child,  one  would  wish  to  avoid  Caesarean 
section  when  it  was  possible  to  deliver  through  the  natural 
passages.  One  would  prefer  to  deal  only  with  those  structures 
which  must  be  eliminated  from  the  body,  avoiding  injury  to 
neighbouring  tissues,  and  leaving  the  parts  which  remain  as 
intact  as  possible.  The  condition  in  which  a  dead  foetus 
passes  through  the  natural  outlet  is  quite  immaterial,  whether 
entire,  with  a  perforated  skull,  or  in  shreds  and  pieces,  as  in 
embryotomy. 

Morcellement,  by  diminishing  the  solid  tumour  mass, 
accomplishes  exactly  the  same  purpose  as  that  achieved  by 
perforation  in  case  of  hydrocephalus,  or  by  embryotomy  on 
the  dead  child  in  cases  of  contracted  pelvis.  The  manipu- 
lation here  occurs  only  upon  those  parts  which  must  be 
sacrificed  and  eliminated  from  the  body  at  any  price. 
/Esthetical  considerations  of  the  nature  and  manner  of  its 
diminution  do  not  arise ;  the  welfare  of  the  patient  is  the 
sole  and  exclusive  care. 

It  is  often  astonishing  how  easily  a  myoma,  whose  size 
absolutely  prevents  its  entering  the  pelvic  canal,  may  be 
delivered  by  this  route  after  excising  only  a  small  portion 
of  its  mass.  But  this  is  readily  explained  by  referring  to 
similar  conditions  in  obstetrics.  A  conjugata  vera,  too 
narrow  by  i  centimetre,  may  render  the  normal  course  of 
labour  impossible,  wrhile,  on  the  other  hand,  a  corresponding 

4 


50  THE  VAGINAL  RADICAL  OPERATION 

slight   change   of  the   size -relations   suffices   to    make   the 
delivery  quite  easy  per  vias  naturales. 

While  in  obstetrics  the  piecemeal  extirpation,  embryotomy, 
is  necessarily  an  irregular  procedure,  these  methods  have 
been  so  far  developed  in  the  vaginal  radical  operation  that 
we  may  distinguish  a  symmetrical  and  an  asymmetrical 
morcellement.  The  one  or  the  other  is  indicated  according 
to  the  more  or  less  symmetrical  relations  present  in  the 
individual  case.  For  a  non-enlarged  uterus  situated  in  the 
median  line  one  would  employ  Pean's  geometrically  regular 
morcellement  ;  for  a  symmetrical  transverse  hypertrophy 
the  V-,  Y-  and  disc-shaped  incisions  ;  and  in  the  completely 
irregular  nodular  contour  the  incisions  must  be  made  to  suit 
the  requirements  of  the  case.  Under  the  asymmetrical 
methods  are  included  also  the  enucleation  of  fibromata  by 
incision  of  their  capsule  and  the  simple  resection  of  such 
when  pedunculated. 

In  the  irregular  morcellement,  one  either  cuts  away  portions 
of  the  mass  successively,  working  from  the  middle  and  under- 
mining the  capsule,  or,  beginning  at  the  free  periphery,  the 
tumour  is  boldly  cut  into  where  most  convenient,  and  larger 
or  smaller  wedge-shaped  blocks  and  sections  brought  away. 
The  shape  of  the  wedges  and  slices  so  removed  is,  of  course, 
always  irregular  and  variable. 

In  all  the  methods  of  morcellement,  as  in  all  the  vaginal 
extirpations,  the  chief  aim  and  principle  throughout  the 
whole  operation  is  this  :  primary  enucleation  of  the  diseased 
organs,  and  formation  of  the  pedicle.  In  embryotomy  one 
dissects  only  as  much  as  is  necessary  to  equalize  the  space 
relations — that  is,  until  the  remaining  portions  of  the  ovum 
can  be  delivered  in  one  mass  ;  likewise  in  the  vaginal  radical 
operation  the  dissection  is  continued  only  until  the  diseased 
structures  can  be  entirely  freed,  and  a  suitable  pedicle  formed. 

Morcellement,  as  stated,  is  chiefly  an  auxiliary  operation, 
and  in  this  sense  this  valuable  procedure  comes  into  use  not 
merely  for  the  vaginal  extraction  of  uterine  tumours,  but 
also  for  intra-ligamentous  fibroids  and  voluminous  tumours 
of  the  adnexa  (ovarian  fibromata,  etc.). 


MORCELLEMENT  AND  H^EMOSTASIS 


CHAPTER  V. 

MORCELLEMENT    AND    H^MOSTASIS. 

IT  may  be  asked,  How  do  we  control  the  haemorrhage  in 
these  dissecting  operations  ?  Are  there  not  great  difficulties 
and  dangers  here  ?  Not  at  all.  On  the  contrary,  we  can 
say  that  in  most  of  these  procedures  we  are  able  so  far  to 
neglect  the  haemostasis  during  the  operation  that  we  can 
develop  with  no  danger  whatever,  and  to  its  fullest  extent, 
our  principle  of  primary  enucleation  and  pedunculation  of 
all  the  structures,  with  secondary  hasmostasis.  Haemorrhage 
during  the  operation  is  controlled  solely  by  the  traction  and 
pressure  of  the  fixation  forceps. 

The  anatomical  conditions  rendering  this  manreuvre  pos- 
sible are  chiefly  these  :  the  main  arteries  supplying  the  uterus 
and  its  appendages,  the  uterine  and  spermatic,  with  their 
accompanying  veins,  lie  wholly  along  the  sides  of  the  womb. 
No  vessels  worth  mentioning  ramify  in  the  para-uterine 
tissues  either  on  the  front  or  back  of  this  organ  ;  and,  what 
is  most  important,  those  entering  the  parenchyma  undergo 
a  rapid  diminution  in  number  and  size  toward  the  median 
line.  Thus,  the  median  portion  is  but  sparely  supplied,  and 
the  sagittal  plane  is  as  little  vascularized  as,  for  instance,  the 
linea  alba  abdominalis. 

A  similar  condition  of  rapidly-diminishing  blood-supply 
is  present  in  the  tumours  of  the  uterus  ;  the  large  arteries 
and  veins  ramifying  on  it  from  the  capsule  undergo  a  rapid 
diminution  toward  the  centre  of  the  tumour.  Consequently, 
the  operator  who  splits  the  uterus  partly  or  wholly  down  the 
middle  line  has  no  haemorrhage  of  importance  to  fear,  because 
he  avoids  the  dangerous  lateral  portions  by  working  as  much 
as  possible  in  the  centre  of  the  tumour.  In  morcellating  the 
uterus,  one  need  not  keep  so  anxiously  in  the  median  line, 
but  may  go  rather  wide  laterally,  provided  that  upon  the 
portions  enucleated  and  delivered  a  constant  traction  is  made 
sufficient  to  close  the  lumina  of  the  smaller  vessels  by  stretch- 
ing and  compression.  It  is  often  surprising  to  see  how 
absolutely  bloodlessly  one  may  operate,  in  spite  of  the 

4—2 


52  THE  VAGINAL  RADICAL  OPERATION 

most  extensive  dissection  of  this  sort,  without  any  necessity 
for  the  primary  (preventive)  application  of  the  clamps,  and 
assisted  merely  by  the  traction  and  compression  of  the  fixation 
forceps. 

From  this  point  of  view,  the  volsellae,  apart  from  their  use 
as  fixation  forceps,  assume  a  very  important  role  as  haemo- 
static instruments  ;  in  fact,  they  are  often  the  only  ones  used 
during  the  whole  operation. 

On  the  other  hand,  when  it  is  absolutely  necessary  to 
begin  the  morcellement  in  the  lateral  portions  of  the  organ, 
where  pieces  of  the  uterus  extending  into  the  vascular  regions 
must  be  extirpated,  then  the  traction  exerted  by  the  forceps 
will  hardly  suffice.  Therefore  in  such  cases  the  haemostasis 
must  be  preventive.  These  are  chiefly  cases  in  which  the 
uterus  is  fixed  by  firm  direct  or  indirect  adhesions,  and,  in 
spite  of  all  efforts,  cannot  at  first  be  loosened ;  or  in  which 
the  fixation  of  the  organ  is  due  to  its  size,  where  only  by 
and  after  the  removal  of  portions  extending  into  the  broad 
ligaments  can  the  remainder  be  set  free.  Here  preventive 
haemostasis  is  the  method  of  necessity,  and  it  not  infre- 
quently so  remains  until  the  very  end  of  the  operation. 
When  anyone  asserts  that  he  has  always  succeeded  in  the 
vaginal  extirpation  without  resorting  to  primary  haemostasis, 
it  only  proves  that  he  has  failed  to  employ  the  operation  in 
a  series  of  cases  which  Pean,  Segond,  and  others  would  have 
attacked  from  the  vagina. 

In  all  such  cases  morcellement  gives  room  for  further 
work,  but  does  not  allow,  at  the  outset,  the  uninterrupted 
progress  of  the  enucleation  and  pedunculation  of  the  struc- 
tures; therefore  the  control  of  the  vessels  by  the  clamps  must 
always  precede  the  resection. 

But  in  all  other  cases  where  the  method  suffices  to  give 
room  and  mobility  without  cutting  into  the  broad  ligaments, 
and  where  the  upper  portions  can  be  successively  reached 
and  brought  down  with  the  formation  of  a  pedicle,  the 
hcemostasis  is  purposely  left  as  the  closing  act  of  the  operation, 
and  according  to  choice  the  clamp  or  ligature  can  be  used. 
So  it  is  in  a  great  majority  of  the  cases  where  the  uterus  is 
split,  and  also  in  many  morcellements ;  and,  in  general,  in 
all  piecemeal  extirpations  where  preventive  clamping  has 


CLASSIFICATION  53 


been  at  first  employed,  and  where  in  the  course  of  the 
operation  it  becomes  possible  to  enucleate  the  remainder  of 
the  organ  or  tumour  primarily. 

From  this  it  follows  that  there  is  no  definite  correlation 
between  morcellement  and  clamps,  nor  between  the  former 
and  preventive  haemostasis. 

In  the  same  sense  the  following  corollary  may  be  deduced 
in  reference  to  the  vaginal  morcellation  of  myomata  :  As 
there  is  no  absolute  rule  determining  the  form  of  morcelle- 
ment, there  is  also  no  definite  method  of  haemostasis,  either 
preventive  or  consecutive. 


CHAPTER  VI. 

OUR    CLASSIFICATION    OF    THE    VAGINAL    RADICAL    OPERATION 

ACCORDING      TO      ITS      USES THE      INDICATIONS     BASED 

UPON    TOPOGRAPHICAL    ANATOMY. 

FOR  the  description  which  we  are  about  to  give  of  the 
special  technique  of  the  vaginal  radical  operation,  we  dis- 
tinguish the  following  groups  : 

A.  Removal    of    structures    without     mutilation    of    the 

uterus : 

(a)  When  the  uterus  is  movable. 
(6)  When  the  uterus  is  fixed. 

B.  Removal  of  structures  with  mutilation  of  the  uterus 

(Morcellation)  : 

(a)  Splitting  the  uterus. 

1.  Median  incision  of  one  wall. 

2.  Total  median  section. 
(6)  Morcellement. 

1.  Symmetrical. 

(a)  With  V-,  Y-  and  disc-shaped  incisions. 

(/3)  Bilateral  incision,  with  removal  of  the 

intervening  horizontal  sections. 

2.  Irregular. 

(a)  When  the  uterus  is  of  normal  size. 
(/3)  When  the  uterus  is  enlarged. 


54  THE  VAGINAL  RADICAL  OPERATION 

While  the  operative  treatment  of  the  uterus  is  selected  as 
the  basis  of  this  classification,  the  procedures  to  be  described 
include  and  contemplate  in  every  case  the  removal  of  the 
adnexa  as  well ;  in  fact,  the  condition  of  the  latter  frequently 
decides  the  method  of  the  extirpation. 

Therefore  the  above  classification  is  not  chosen  arbitrarily, 
but  depends  on  the  anatomical  conditions  of  the  individual 
case.  The  procedure  shapes  itself  mainly  according  to  the 
local  anatomical  changes  present,  and  the  mechanical  cir- 
cumstances, such  as  the  size  and  fixation  of  the  uterus  and 
its  appendages,  taken  as  a  whole. 

It  is  thus  immaterial  whether  the  increased  size  of  the 
organs  depends  on  myoma,  pyosalpinx,  etc. ;  or  whether  the 
fixation  is  due  to  old  cicatricial  parametritis,  to  intra- 
peritoneal  adhesions,  or  to  tumour  of  the  appendages  which 
wall-in  the  uterus. 

We  shall  therefore  dispense  with  a  classification  based  on 
pathological  indications,  for  that  would  only  lead  to  mere 
repetition.  Such  a  scheme,  where  one  of  the  above-named 
methods  would  always  correspond  to  a  particular  pathologi- 
cal condition,  is  impossible.  The  reverse  is  oftener  the  case, 
where  a  single  operative  procedure  is  necessary  for  many 
anatomical  conditions  differing  in  cause  and  location. 

Sometimes,  on  account  of  special  circumstances,  the  case 
may  demand  transition  forms,  or  combinations  of  the 
methods  to  be  described ;  then  the  '  mixed '  operation 
becomes  necessary — such  is,  for  instance,  symmetrical 
morcellement  of  the  lower  uterine  segment  followed  by 
sagittal  section  of  the  remainder  of  the  organ. 

Whoever  studies  the  various  stages  of  the  extirpation 
methods  to  be  now  described  will  recognise  the  justice  of  the 
statement  that  this,  the  most  radical  of  all  methods  in  its 
final  results,  may  nevertheless,  during  its  performance,  be 
converted  at  will  into  a  conservative  procedure. 

The  carrying  of  it  out  in  practice  naturally  includes  the 
possibility  of  the  carrying  out  of  all  the  above-mentioned 
daughter-operations. 


PREPARATION  OF  THE  PATIENT  55 


B.— SPECIAL  TECHNIQUE. 

CHAPTER  I. 

PREPARATION  OF  THE  PATIENT — THE  ANAESTHETIC,  THE 
ASSISTANTS,  ETC. 

PREPARATIONS. 

THE  preparation  of  the  patient  differs  in  no  particular  from 
that  usual  for  major  operations.  The  important  points  are  : 
Thorough  emptying  of  the  bowel  by  administration  of  castor- 
oil,  and  by  rectal  irrigation,  the  latter  several  hours  before 
the  operation ;  careful  cleansing  of  the  external  genitals ; 
when  possible  shaving  away  the  hair  a  day  or  so  previous 
to  the  operation  ;  full  bath ;  local  disinfection  of  the  entire 
field  of  operation  and  the  adjacent  parts  :  vulva,  vagina, 
cervix,  thighs,  and  lower  abdomen. 

Although  we  employ  antiseptics  (alcohol  and  perchloride 
i  :  1000)  for  the  pre-operative  cleansing,  we  lay  the  greatest 
stress  upon  the  mechanical  cleansing  by  the  vigorous  use 
of  soap  and  brush.  The  thorough  removal  of  decomposing 
ichorous  masses  of  carcinoma  before  the  operation  is  dangerous 
on  account  of  the  possibility  of  further  implantation  of  virulent 
cancer  particles.  Here  the  danger  of  inoculation  increases 
pan  passu  with  the  effort  to  be  radical. 

The  patient  comes  to  the  operation  in  a  clean  long  gown 
and  long  stockings.  Before  every  operation  the  bladder  is 
emptied  by  a  catheter  as  soon  as  the  patient  is  under  the 
anaesthetic.  It  may  be  stated  in  advance  that  during  or 
after  the  operation  no  antiseptics  whatever  come  in  contact 
with  the  field  of  operation  or  the  wound.  Especially  do  we 
emphasize  the  point  that,  as  a  routine  principle,  all  irrigation 
during  the  operation,  even  with  sterilized  water,  is  dispensed 
with.  Even  when  the  field  of  operation  is  soiled  with 
stinking  ichorous  pus  (pyosalpinx,  pyometra),  we  do  not 
irrigate  ;  the  infectious  material  is  simply  wiped  away  with 
dry  sterilized  gauze  or  sponges. 


56  THE  VAGINAL  RADICAL  OPERATION 

ANAESTHESIA. 

For  the  last  five  years  we  have  used  nothing  but  ether  for 
the  narcosis,  and  only  in  very  exceptional  cases  do  we  sub- 
stitute chloroform  for  it.  These  exceptions  are  cases  of 
nephritis  and  catarrhal  affections  of  the  respiratory  organs, 
although  here  even  the  use  of  chloroform  does  not  entirely 
obviate  some  important  drawbacks.  In  over  2,000  anaesthesias 
in  our  clinic,  ether  has  given  such  good  results  that,  apart 
from  these  exceptions,  we  regard  the  use  of  chloroform  as  a 
retrograde  step.  Among  our  patients  we  have  scarcely  ever 
observed  a  really  injurious  effect  of  the  ether  upon  either 
life  or  health,  even  if  we  include  the  fatal  cases,  where  it 
would  be  very  convenient  to  ascribe  the  cause  of  death  to 
the  effects  of  the  anaesthetic.  Moreover,  since  ether  affects 
the  heart  the  least  of  all  the  anaesthetics,  its  value  is  self- 
evident,  especially  for  those  patients,  by  no  means  few,  with 
myoma  or  carcinoma,  who  are  weakened  by  losses  of  blood, 
and  whose  anaemic  dyscrasia  may  have  already  led  to  fatty 
changes  in  the  heart  muscle. 

It  is  also  to  be  noted  that  it  is  not  only  a  question  of  the 
chemical  purity  of  the  ether  or  of  the  kind  of  mask  used,  but 
also  of  a  rational  and  sensible  technique.  It  does  not  do  to 
suffocate  a  patient  as  rapidly  as  possible,  and  render  her 
unconscious  from  carbonic  acid  intoxication ;  much  rather 
should  a  quiet  sleep  be  slowly  produced,  and  the  state  of 
unconsciousness  be  maintained  by  giving  as  little  ether  as 
possible.  Here,  exactly  as  with  chloroform,  one  should 
administer  just  as  little  as  may  be  necessary  to  keep  the 
narcosis  going,  not  forgetting  meanwhile  that  even  when 
anaesthetized  a  person  cannot  live  without  oxygen.  It 
follows,  therefore,  that,  after  the  patient  is  once  asleep,  the 
anaesthetist  should  remove  the  mask  from  the  face  as  often 
and  for  as  long  a  time  as  possible. 

The  saliva  that  collects  is  most  effectively  removed  by 
turning  the  patient's  head  to  one  side,  and  carefully  sponging 
out  the  mouth,  in  this  way  getting  rid  of  one  of  the  causal 
agents  of  aspiration-bronchitis  and  pneumonia. 


THE  OPERATING  TABLE 


57 


OPERATING  TABLE. 

This  may  be  of  any  desired  form  or  kind,  but  experience 
has  shown  that  the  most  serviceable  is  one  that  combines 
the  following  advantages  :  First,  the  possibility  of  raising  its 
bed  to  any  height ;  second,  a  rapid  but  not  jerky  transition 
to  Trendelenberg's  position,  and  its  reverse  (low  pelvic  posi- 
tion) ;  and  third,  the  convenient  changing  from  the  lithotomy 
to  the  ordinary  laparotomy  position,  and  vice  versa.  A  table 
that  combines  these  principles  has  been  constructed  by 


FIG.  i. — OPERATING  TABLE. 

L.  Landau  and  Dr.  Vogel.  The  undertaking  of  a  grave 
vaginal  operation  without  some  such  table  is  all  the  less 
justifiable  because  everyone  who  commences  such  an  opera- 
tion must  be  prepared  to  finish  it  with  a  laparotomy,  when 
necessary,  to  carry  out  the  principle  of  radical  extirpation. 
We  present  here  only  the  illustration  of  our  table  (Fig.  i)  ; 
a  detailed  description  was  published  some  time  ago.1 

1Vogel,    '  Landau- Vogel    Operationstisch,'    '  Berl.    Klinische    Woch.,' 
No.  16,  1895. 


58  THE  VAGINAL  RADICAL  OPERATION 

POSITION  OF  THE  PATIENT — THE  OPERATOR'S  POSITION. 

The  operator  may  stand  or  sit,  according  to  his  convenience. 
The  patient  lies  in  the  sacro-dorsal  position,  and,  in  case  the 
operator  chooses  to  sit,  may  be  brought  into  the  Sims 
abdomino-lateral  position  (Pean).  In  this  the  patient  lies 
on  the  left  side,  the  right  thigh  is  drawn  up  toward  the 
breast,  the  left  leg  is  extended  ;  the  table  is  on  a  level  with 
the  operator's  breast. 

With  the  patient  in  the  sacro-dorsal  position,  the  operator, 
according  to  the  number  of  his  assistants,  may  allow  the 
legs,  abducted  and  slightly  flexed  at  knee  and  hip,  to  rest  in 
the  leg-holders  (see  Fig.  i),  or  the  thighs  may  be  strongly 
flexed  on  the  abdomen,  and  held  by  the  assistants,  or  by  a 
crutch,  thus  bringing  the  patient  into  the  typical  lithotomy 
position.  The  operator  himself  sits  or  stands  between  the 
patient's  thighs,  naturally  at  a  height  corresponding  to  the 
field  of  operation. 

In  every  position  of  the  patient  there  are  two  points  to  be 
attended  to  :  first,  that  the  head  be  not  propped  against  the 
chest,  which  would  disturb  the  respiration  and  the  narcosis ; 
and  second,  that  at  any  moment  during  the  operation  it  shall 
be  possible  to  change  the  position  to  a  certain  degree  of  pelvic 
elevation,  easily  and  without  disorder.  The  above-mentioned 
table  seems  especially  capable  of  fulfilling  this  latter  con- 
dition. 

There  can  be  no  general  rule  or  direction  laid  down  for 
the  placing  of  the  operator  or  patient  so  that  certain  indi- 
cations shall  always  correspond  to  certain  positions.  All 
positions  are  possible,  and  all  are  serviceable  ;  each  has  its 
own  advantages  and  disadvantages. 

We  have  tried  all  possible  positions,  and  have  found  the 
sacro-dorsal  to  be  the  most  convenient,  the  operator  sitting 
between  the  patient's  thighs. 

NUMBER  AND  PLACES  OF  THE  ASSISTANTS — LEG-STRAPS. 

As  someone  has  said,  in  every  major  operation  two 
assistants  are  better  than  three,  one  is  better  than  two,  and 
none  at  all  is  still  better.  Certainly,  he  who  can  rely  entirely 


DUTIES  OF  THE  ASSISTANTS  59 

upon  his  own  efficiency  is  to  be  envied,  but  in  the  vaginal 
operations  to  be  described  this  is  not  possible  ;  one  assistant 
at  least  is  always  necessary.  The  number  of  assistants  is 
governed  by  the  position  of  the  patient ;  thus,  for  instance, 
the  operator  (Pean)  employing  the  abdomino-lateral  position 
needs  two  assistants,  and  strong  ones,  solely  to  maintain  the 
patient  in  this  position  undisturbed.  Likewise,  everyone 
who  operates  in  the  dorso-saeral  position  must  have  two 
assistants  if  he  dispenses  with  the  leg-straps.  By  trusting 
the  patient's  legs  to  this  latter,  one  can  get  along  with  but 
one  assistant,  handling  the  instruments  one's  self  (Doyen). 

For  our  part,  we  use  the  dorso-sacral  position,  work 
sitting,  and,  as  a  rule,  do  not  use  the  leg-straps  ;  in  addition 
to  the  two  assistants  holding  the  patient's  knees,  we  have 
a  third  who  sits  at  the  left.  The  assistants  standing  at 
the  right  and  left,  and  facing  the  operator,  have  each  to 
support  the  sharply-flexed  leg  of  the  patient,  so  that  with  the 
corresponding  elbow  the  thigh  is  held  in  flexion,  and  the  leg 
rests  across  his  back.  Naturally,  the  assistants  having  this 
task  must  not  regard  the  patient's  thighs  as  a  welcome  rest 
for  their  weary  arms.  Thrombosis  of  the  femoral  vein  may 
be  the  deplorable  result  of  such  thoughtlessness,  and  even 
with  the  use  of  the  mechanical  leg-supports,  such  a  result 
can  be  laid  to  the  assistant's  account  rather  than  to  the 
ether.  One  must  also  bear  in  mind  that  an  unreasonably 
strong  flexion  of  the  thigh  against  the  abdomen  disturbs  the 
breathing  and  the  narcosis. 

To  the  assistant  standing  at  the  operator's  right  falls  the 
especial  duty  of  marking  off  the  limits  of  the  field  of  opera- 
tion with  the  retractor,  and  of  holding  back  the  vaginal  wall, 
together  with  the  paracervical  tissue,  as  these  are  gradually 
separated  from  the  uterus,  so  protecting  the  bladder  and 
ureters  with  his  instrument.  It  also  devolves  on  him, 
according  to  the  operator's  direction,  to  retract  the  left  side 
of  the  vagina,  and  to  hold  the  instruments  (claw  forceps  and 
clamps)  applied  to  the  left  half  of  the  uterus  and  left  adnexa. 
In  the  same  way  the  assistant  at  the  left  must  retract  the 
right  side  of  the  vagina,  and  take  care  of  the  instruments 
applied  to  the  corresponding  half  of  the  internal  genitalia. 


60  THE  VAGINAL  RADICAL  OPERATION 

The  third  assistant,  who  sits  at  the  operator's  left,  depresses 
the  posterior  vaginal  wall  strongly  downward  and  backward 
with  a  flat  speculum,  and,  when  necessary,  takes  charge  of 
the  claw  forceps,  which  are  fastened  on  the  uterus  and 
tissues  to  be  extirpated.  Besides  these  we  need,  of  course, 
an  anaesthetist,  and  generally  have  a  nurse  to  hand  us  the 
instruments. 

The  large  number  of  assistants  need  not  frighten  the 
aseptic  enthusiast,  for  the  assistants'  roles  are  wholly  non- 
active.  They  do  not  touch  the  wound  with  their  fingers  in 
any  way,  have  nothing  but  the  instruments  to  handle,  and 
have  chiefly  the  duty  of  exposing  and  retracting  the  field  of 
operation. 


CHAPTER  II. 

ARMAMENTARIUM  :     INSTRUMENTS    AND    DRESSINGS. 

ONE  must  not  be  sparing  in  the  number  of  his  instruments. 
In  many  cases,  it  is  true,  only  a  few  are  required,  but  at  the 
start  one  can  never  tell  but  that  in  the  course  of  the  operation 
a  great  many  will  be  necessary,  hence  a  larger  number  should 
always  be  in  readiness. 

In  the  operation  under  discussion,  all  the  instruments  used 
by  us,  without  exception,  are  made  of  steel,  hard  soldered 
and  nickel-plated.  They  are  easily  and  thoroughly  sterilized 
— naturally  after  a  preceding  mechanical  cleansing — by  half 
an  hour's  boiling  in  a  i  per  cent,  soda  solution,  and  during 
the  operation  they  lie  in  the  same  fluid. 

Out  of  the  great  number  of  models  devised  by  various 
operators,  we  have  selected  a  relatively  small  number  as 
being  always  useful  (Figs.  3-16). 

i.  RETRACTORS  OR  ECARTEURS. 

For  the  posterior  vaginal  wall  we  employ  a  simple  perineal 
retractor  with  a  narrow  or  broad,  long  or  short  blade, 
according  to  the  size  and  elasticity  of  the  vagina  and 
mobility  of  the  uterus.  We  prefer  the  short,  slightly  con- 


A  RMA  ME  XT  A  RIUM  6  r 

cave  blade  (Fig.  3  b),  which  is  only  5  cm.  long  and  4  cm. 
broad.  Besides  this,  one  other  speculum  of  the  same  shape, 
8  cm.  long  and  4  cm.  broad  (.Fig.  3  a). 

For  the  lateral  and  anterior  vaginal  walls  we  use  the  form 
of  retractor  seen  in  Figs.  4  a,  46;  two  of  these  have  a  blade 
10  cm.  long,  and  two  12  cm. ;  all  are  2f  cm.  wide.  They  are 
easily  introduced  as  far  as  the  large  pelvis  and  abdominal 
cavity.  The  one  applied  to  the  anterior  vaginal  wall  serves 
not  only  as  a  retractor,  but  also  as  an  elevator  and  raspatory 
for  the  soft  parts  concerned. 

The  action  of  the  retractors  is  chiefly  one  of  leverage  ;  the 
symphysis  and  horizontal  and  descending  rami  of  the  pubes 
and  the  ascending  rami  of  the  ischium  form  a  temporary 
fulcrum  for  this  two-armed  lever. 

The  nickel-plating  of  the  blades  increases  their  light- 
reflecting  power. 

In  addition  to  their  chief  use  in  exposing  the  field  of 
operation,  all  these  retractors  have  the  important  function  of 
protecting  the  adjacent  organs — bladder,  ureters,  and  bowel. 

The  short  lateral  retractors,  Pean's  long  right-angled 
ecarteurs,  and  Segond's  curved  ecarteurs  are  certainly  very 
handy,  but  are  all  amply  replaced  by  the  instruments  just 
described. 

Auvard's  weighted  speculum  is  as  inconvenient  as  it  is 
useless ;  only  too  frequently  it  bores  into  the  posterior 
vaginal  wall,  making  deep  lacerations  which  bleed  profusely. 

It  must  be  remembered  that  the  position  of  the  retractors 
has  always  to  correspond  to  the  position  of  the  organs,  and 
has  therefore  to  be  changed  from  time  to  time  during  the 
operation.  Thus,  the  number,  place,  and  kinds  of  specula 
vary  constantly,  and  the  retracting  surfaces  of  the  instru- 
ments will  be  of  correspondingly  greater  or  smaller  extent. 

In  simple  cases  of  mobile  non-enlarged  uteri,  the  use  of 
specula  is  quite  limited ;  often  two  short  retractors  are  quite 
sufficient. 

2.  FIXATION  INSTRUMENTS  (VOLSELL.E). 
(a)  A  serviceable  condition  of  the  claw  forceps  used  for 
fixation  is  absolutely  necessary  to  the  safe  execution  of  every 


62 


THE  VAGINAL  RADICAL  OPERATION 


radical  operation,  for  in  addition  to  grasping  and  holding 
the  tissues,  they  have  the  still  more  important  task  of  con- 
trolling the  haemorrhage  by  traction  and  pressure. 


VAGINAL  RADICAL  OPERATION  APPLIANCES. 

FIGS.  3 a,  36,  4 a,  46. — Vaginal  Retractors. 

FIG.  9. — Ovary  Forceps  (Doyen). 

FIG.  15. — Sickle-shaped  Knife,  with  Raspstory  Handle  (Brennecke). 

FIGS.  5,  7 a,  jb,  'jc. — Volsellae. 


In  well-made  volsellae  the  teeth   stand  perpendicular,  or 
at  an  acute  angle  to  the  jaws  (Figs.  5,  6). 


A  RMA  ME  NT  A  RI UM 


We  use  four-  and  six-toothed  volsellse  of  correspondingly 
increasing  strength,  from  0*6  to  1*4  cm.  broad  at  the  end. 
Figs.  7,  a,  b,  c,  show  the  natural  size  of  the  ends. 


VAGINAL  RADICAL  OPERATION  APPLIANCES. 

FIGS.  10 a,  10 b,  IQC,  na,  116,  nr. — Broad  Ligament  Clamp  (Doyen,  Pean, 

Segond). 
FIGS.  8,  12. — Serrated  Forceps  for  seizing  the  Uterus  in  Morcellation  (Segond 

and  Doyen). 
FIGS.  i6a,  16 b. —Knife  with  Hollowed  Blade,  for  Morcellement  (Landau). 

We  have,  at  least,  eight  of  the  small  and  four  of  the  large 
in  readiness  at  each  operation. 


64  THE  VAGINAL  RADICAL  OPERATION 

(b)  Fenestrated  Forceps. 

(a)  With  Teeth. — Two  or  three  of  Segond's  pattern 
(Fig.  8),  whose  especial  use  is  in  grasping 
portions  of  fibroid  tumour. 

Nelaton's  fenestrated  forceps  may  also  be  used  for 
the  same  purpose. 

(/3)  Without  Teeth. — Four  of  Doyen's  pattern,  similar 
to  Collin's  tongue  forceps  (Fig.  9).  Length 
17  cm.,  but  shorter  ones  may  be  used  also. 
They  are  chiefly  used  in  delivering  the  adnexa. 
They  are  somewhat  on  the  principle  of  the 
obstetrical  forceps ;  they  clasp  with  a  broad 
surface,  and,  as  they  are  not  toothed,  will  not 
lacerate  even  the  softest  tissue.  Heavier  and 
longer  instruments  of  this  sort  (length  21  cm.), 
which  we  have  occasionally  tried,  are  not 
necessary. 

3.  CLAMPS. 

At  present  we  use  in  the  vaginal  radical  operation  only 
straight  clamps  without  the  pelvic  curve,  and  prefer  in 
general  the  pattern  with  short  clamping  surface  (4  cm.). 

If  one  wishes  to  follow  Doyen's  precedent,  and  inclose 
the  whole  width  of  the  broad  ligament  in  the  grasp  of  a 
single  clamp  without  dividing  it  first  into  narrower  sections, 
he  must  employ  the  Doyen  spring  forceps,  in  order  that  the 
whole  clamping  surface  may  exert  a  uniform  pressure. 

For  every  operation  we  have  the  following  ready,  sterilized  : 

(a)  2  long  Doyen's  spring  clamps,  with  the  blades  grooved 

in  the  middle,  the  edges  serrated ;  length,  27  cm.  ; 
blades,  locm.  (Figs.  10,  a,  b).  2  of  the  same  length, 
but  lighter,  blades  serrated  (Fig.  10  c).  Doyen  puts 
these  on  inside  the  heavy  clamp  for  security. 

(b)  4  of  Pean's  pattern,  with  long  serrated  blades  ;  length, 

24  cm.  ;  blades,  6  cm.  (Fig.  u  a). 

(c)  6  of  Pean's  pattern,  medium  length,  serrated  blades ; 

length,  24  cm.  ;  blades,  4!  cm.  (Fig.  u  b). 

(d)  6   of  Segond's   pattern,    with  short    serrated   blades  ; 

length,  24  cm. ;  blades,  3  cm.  (Fig.  u  c). 


(e)  6  very  light  haemostatic  forceps  for  seizing  isolated 
vessels,  or  for  clamping  vaginal  and  peritoneal  wound 
edges  (Fig.  12). 

T-shaped   forceps   for  this  purpose  have  no    special 
advantage. 


VAGINAL  RADICAL  OPERATION  APPLIANCES. 

FIGS.  14  a,  146. — Long  Scissors  (straight  and  curved)  for  dividing  the  Uterus 

in  Hysterectomy  (Landau). 
FIG.  6. — Slender-toothed  Clamp  Forceps  (Doyen). 

It  is  advisable  to  choose  light  clamps,  in  order  not  to 
unnecessarily  increase  the  weight  of  the  instruments  lying  in 
the  vagina. 

They  must  be  of  excellent  quality,  and  must  lock  and 
hold  securely,  otherwise  there  is  danger  of  their  slipping  off 
or  springing  open.  This  presupposes  good  material  and 
faultless  work.1 

1  Our  instruments,  furnished  by  Chr.  Schmidt,  Berlin,  answer  fully  to 
the  above  requirements,  especially  the  newer  models  which  he  has  executed 
for  us. 


66  THE  VAGINAL  RADICAL  OPERATION 

The  above  list  of  clamps  represents,  according  to  our 
experience,  the  minimum  number  to  have  in  readiness  for  a 
vaginal  radical  operation,  although,  of  course,  we  cannot 
designate  any  certain  number  as  being  absolutely  requisite. 
Often  a  much  smaller  number  will  suffice,  but,  on  the  other 
hand,  unforeseen  difficulties  may  render  a  still  greater 
quantity  necessary.  Nothing  can  be  more  harmful  to  the 
success  of  the  operation  or  to  the  welfare  of  the  patient 
than  an  incomplete  armamentarium. 

4.  CUTTING  INSTRUMENTS. 

(a)  Scissors : 

One  strong,  heavy,  and  straight  pair,  with  blunt 

points  ;  length,  17  cm. ;  cutting  surface,  7  cm. 

(Fig.  13). 

One  long  straight  pair,  24  cm.  (Fig.  14  a). 
One  same  length,  curved  on  the  flat  (Fig.  14  b)  ; 

cutting  surface  of  each  5  cm. 
As    these    long    instruments    are    intended    for 

deep  work,  it  is  better  not  to  have  the  two 

latter  kinds  sharp-pointed. 
Scissors  with  a  double  curve  are  unnecessary. 

(b)  Scalpels  : 

(a)  For  the  circular  incision  of  the  portio,  if,  instead 
of  the  scissors,  as  used  by   Doyen   and  our- 
selves, the  operator  prefers  the  knife. 
Brennecke's  Knife :  This  has  a  secure  blade  set 
in  a  wooden  handle,  which,  if  it  is  heavy 
enough,  can  be  very  conveniently  used  as 
an  elevator  or  raspatory  (Fig.  15). 

(13)  For  morcellation  : 

One  straight  knife,  23  cm.  long,  with  a  5  cm. 

blade  (Fig.  16  a}. 
One  curved  on  the  flat  with  same  length  of 

handle  and  blade. 

5.  AN  ORDINARY  UTERINE  SOUND. 

6.  A  FEMALE  CATHETER. 


ARMAMENTARIUM  67 


7.  SPONGE  AND  DRAINAGE  MATERIAL. 

Pledgets  of  sterilized  gauze  for  sponging  away  pus 

and  blood. 

Mounted  sponges  for  the  same  purpose. 
Preparation  of  the  Sponges. — Soften  for  a  quarter  of 
an  hour  in  hot  water ;  place  for  two  hours  in 
hydrochloric  acid  solution  i  :  1000  ;  rinse  quarter 
of  an  hour  in  sterilized  water ;  macerate  for 
twelve  hours  in  soap  and  hot  water;  rinse  in 
sterilized  water,  and  preserve  in  5  per  cent, 
carbolic  acid  solution. 

Sterilized  gauze  strips,  6  cm.  wide,  75  cm.  long. 
In  the  change  from  antisepsis  to  asepsis  we  have  entirely 
given  up  iodoform  gauze. 

Besides  the  instruments,  several  basins  are  needed  for 
disinfection  of  the  hands,  alcohol,  perchloride  solution 
i  :  1000,  soap,  brushes,  etc. 

One  must  be  prepared  to  finish  with  a  laparotomy  if 
necessary,  in  order  to  complete  the  radical  procedure  in  case 
of  a  technically  difficult  vaginal  operation.  Therefore  it  is 
advisable  to  have  the  necessary  laparotomy  instruments  at 
hand,  needle  for  abdominal  suture,  silk,  catgut,  silver  wire, 
small  forceps,  etc. 

When  the  operator  so  desires,  the  thermo-cautery  may  be 
held  in  readiness  for  circular  incision  of  the  portio,  for  other 
incisions,  or  for  cauterizing  cancerous  surfaces  (Jacobs). 

For  exposing  the  uterus  and  adnexa,  one  may  use  Simon's 
lateral  retractors,  or  long  or  short  right-angled  retractors. 
A  straight  grooved  director  may  be  employed  as  a  guide  in 
splitting  the  uterus,  or  instead  of  the  straight  clamps  we 
may  choose  those  with  a  pelvic  curve.  All  this  is,  of  course, 
subject  to  the  operator's  individual  preference. 

The  short  bistouries,  the  long  surgical  forceps,  bullet 
forceps  for  fixing  the  portio,  forceps  with  gilded  rings  or 
otherwise  specially  marked  as  sponge-holders — these,  and 
others  which  figure  in  various  instrument  lists,  we  consider 
quite  superfluous. 

So,  also,  the  long  curved  knives  with  various  blades,  for 
right  and  left  incision,  can  be  spared. 

5—2 


68  THE  VAGINAL  RADICAL  OPERATION 


CHAPTER  III. 

TECHNIQUE  OF  THE  VARIOUS  FORMS  OF  THE  OPERATION- 
REMOVAL  OF  THE  APPENDAGES  AND  MOBILE  UTERUS 
WITHOUT  MORCELLEMENT. 

THIS  method  of  operation  is  applicable  when  we  have  to 
deal  with  mobile  uteri  which  are  not  greatly  enlarged,  and 
which  admit  of  downward  traction ;  in  its  scope  it  corresponds 
to  the  original  ligature  method  in  general  use.  It  is  therefore 
indicated  in  localized  carcinoma  or  sarcoma  of  the  cervix  or 
corpus  uteri,  and  in  myomata  up  to  the  size  of  a  man's  fist, 
when  these  cannot  be  enucleated  alone ;  in  cases  of  bilateral 
suppuration  of  the  tubes  and  ovaries  when  the  tubal  disease 
is  chiefly  lateral,  and  does  not  interfere  with  the  mobility  of 
the  womb,  and  hence  in  bilateral  ovarian  abscess  and  in 
pyosalpinges  whose  proximal  portions  are  relatively  free  ; 
finally,  in  certain  cases  of  true  ovarian  tumours  of  both 
sides,  when  not  too  large. 

For  convenience  of  description,  we  divide  the  operation 
into  successive  stages.  In  this  description  it  will  be  neces- 
sary to  discuss  incidentally  a  number  of  points,  such  as  the 
situation  of  the  bladder  and  ureters,  the  method  of  applying 
the  clamps,  etc.,  which  are  of  equal  importance  in  relation 
to  each  of  the  methods  to  be  taken  up  later.  They  will 
therefore  be  noted  in  this  section  as  opportunity  offers. 

FIRST  STAGE  :  EXPOSING  AND  FIXING  THE  PORTIO. 

This  includes  the  introduction  of  the  short  broad  retractors 
along  the  anterior  and  lateral  walls,  bringing  the  portio  into 
view,  and  fixation  of  the  same  with  four -claw  forceps 
(volsellae),  one  applied  to  the  middle  of  the  anterior  lip  close 
to  the  external  os,  one  at  each  side  in  the  posterior  lip 
equidistant  from  the  centre.  These  volsellae  may  be  pushed 
well  up  into  the  cervical  canal  without  fear  of  endangering 
neighbouring  structures. 

With  the  volsellae  so  applied,  the  uterus  responds  readily 
to  traction,  if  it  is  at  all  movable,  often  coming  quite  into 


EXPOSING  AND  FIXING  THE  PORTIO 


69 


the  vulva.  The  two  volsellse  on  the  posterior  lip  remain  in 
place  until  the  end  of  the  operation  merely  as  a  convenient 
topographical  landmark  ;  but  in  certain  cases  they  are  very 
useful  in  drawing  the  portio  to  one  side  or  the  other,  in 
order  to  bring  the  broad  ligaments  within  reach.  For  the 
same  reason  we  do  not  remove  the  volsella  from  the  anterior 
lip  unless  the  womb  is  to  be  opened  along  its  front  wall,  as 
occurs  in  other  methods. 


FIG.  17. — FIXING  THE  PORTIO  VAGINALIS. 

Many  operators  apply  the  volsellae  in  a  different  way ; 
some  place  a  forceps  upon  each  lip,  and,  in  order  to  prevent 
their  interfering  with  each  other,  apply  the  anterior  a  little 
to  the  right,  the  posterior  slightly  to  the  left  of  the  median 
line  (Fig.  17).  Others  seize  each  lateral  commissure  with  a 
volsella.  Naturally,  there  is  no  difficulty  in  fixing  the  forceps 


70  THE  VAGINAL  RADICAL  OPERATION 

on  an  intact  portio ;  but  when  ulcerating  new  growths  are 
present  it  is  different.  Here  that  portion  of  the  lower  uterine 
segment  which  is  to  be  seized  must  be  first  prepared  ;  the 
soft  and  friable  tissue  must  be  removed  by  means  of  scissors, 
curette,  or  cautery  until  the  forceps  can  find  a  firm  hold  on 
the  underlying  sound  muscular  tissue. 

The  fact  that  injuries  to  the  structures  not  extirpated 
(vagina)  may  become  dangerous  through  inoculation  makes 
it  advisable  to  use  great  care  in  preparing  the  portio 
when  this  becomes  necessary.  In  order  to  avoid  a  septic 
or  purulent  infection,  we  never  subject  a  cancerous  cervix 
to  a  '  cleansing  process.'  Contrary  to  the  practice  of  some 
surgeons,  we  do  not  remove  the  tumour  a  day  or  so  before 
the  hysterectomy  by  a  special  operation,  for  to  do  so  seems 
to  us  to  be  attended  with  nothing  but  harm,  useless  anxiety 
for  the  patient,  and  a  repetition  of  the  anaesthesia ;  hence 
we  always  operate  at  one  sitting. 

In  cancer,  on  account  of  its  manifold  forms,  there  is  no 
question  of  symmetrical  application  of  the  forceps,  and  it  is 
at  first  sufficient  to  procure  a  firm  hold,  which  may  serve  as 
a  point  of  leverage,  and  a  starting-place  for  further  manipu- 
lations. It  is  especially  desirable  to  hook  firmly  into  the 
posterior  lip,  or,  when  this  is  destroyed  by  cancer,  into  the 
posterior  uterine  wall,  and  here  one  can  go  far  up  into  the 
cervical  canal,  for  the  neighbouring  organs  are  out  of  the  way 
of  danger.  The  same  principle  holds  good,  as  previously 
mentioned,  in  case  of  an  earlier  cervix  amputation,  or  in 
senile  atrophy  of  the  portio,  viz.,  to  always  begin  by  securing 
a  firm  hold  of  the  posterior  lip  when  possible. 

In  pyometra  or  in  malignant  tumours  of  the  corpus  uteri, 
in  order  to  prevent  the  oozing  out  of  infectious  material,  one 
may  use  the  device  of  catching  up  and  fastening  both  lips 
together  with  a  volsella,  in  this  way  closing  the  cervical 
canal  and  external  os  during  the  operation. 

Finally,  some  operators,  for  fear  of  the  risk  of  infection 
from  an  inflamed  endometrium,  make  it  a  rule  to  precede 
every  hysterectomy  with  a  curetting.  We  mention  this 
merely  for  the  sake  of  completeness  ;  it  needs  no  comment. 


INCISION  OF  THE  PORTIO  71 

SECOND  STAGE  :  CIRCULAR  INCISION  OF  THE  PORTIO— 
VARIOUS  INCISIONS — EXPLORATORY  INCISION. 

In  normal  conditions  we  incise  the  portio  by  means  of  a 
straight  scissors,  giving  the  wound  an  oval  or  elliptic  form 
(Fig.  18).  Beginning  in  front  above,  and  as  close  as  possible 
to  the  os  externum,  the  incision  is  carried  along  laterally 
exactly  in  the  line  of  the  gaping  wound  in  the  mucous 
membrane,  and  at  the  same  distance  from  the  os.  The 
portio  is  pulled  upwards  and  forwards  by  the  forceps,  and 
the  circle  is  completed  by  an  incision  which  opens  the 
posterior  vaginal  vault,  or  at  least  extends  farther  from  the 
os  toward  the  cul-de-sac  than  the  anterior  incision  does. 
The  rule  is  to  direct  the  cutting  instrument  always  per- 
pendicularly against  the  uterine  parenchyma,  severing  the 
fascicles  of  tissue  in  this  favourable  direction,  as  they  are 
made  tense.  By  keeping  the  upper  and  lateral  portion  of 
the  incision  close  above  the  os,  the  bladder  and  ureters  are 
protected  without  any  preliminary  exploration  by  the  catheter 
or  by  vesical  injection.  Posteriorly  the  reverse  is  the  case, 
and  the  incision  is  carried  higher  up,  because  here  one 
prepares  the  way  to  reach  the  posterior  reflection  of  the 
peritoneum  in  the  following  stage  rapidly,  without  endanger- 
ing neighbouring  organs,  and  without  getting  confused  in 
the  different  layers  of  the  peri-rectal  connective  tissue.  This 
incision  not  infrequently  opens  Douglas'  cul-de-sac,  and 
thereby  the  peritoneum,  at  once.  However,  it  should  not 
be  unnecessarily  overdone  ;  when  the  wound  heals  after  a 
too  extravagant  excision,  the  vagina  may  be  so  narrowed 
and  shortened  as  to  render  coitus  difficult. 

Naturally,  the  outline  of  the  first  incision  cannot  be  regular 
in  cases  where  the  portio  is  brittle  or  eroded  by  cancer  ; 
where  the  vagina  is  also  involved  in  the  malignant  process  ; 
where  mutilating  operations  have  previously  been  performed 
on  the  cervix ;  or  where  physiological  atrophy  of  the  cervix 
coexists  with  atresia  of  the  vault.  Here,  as  in  the  applica- 
tion of  the  volsellse,  it  depends  on  the  anatomical  relation 
present. 

For  carrying  the  incision  through  macroscopically  sound 


72  THE  VAGINAL  RADICAL  OPERATION 

tissue  in  the  presence  of  malignant  new  growths,  it  is 
relatively  more  favourable  when  the  cancer  has  extended  on 
to  the  posterior  wall,  for  then  the  circular  incision  can  be 
begun  close  to  the  introitus  vaginae. 


FIG.  18.  —  COMMENCEMENT  OF  THE  CIRCULAR   INCISION  ON  THE  ANTERIOR 
SURFACE  OF  THE  CERVIX,  THE  NECK  BEING  DRAWN  OUT  OF  THE  VULVA 

WITH    VOLSELL^E. 

The  incision  may  be  made  with  the  scalpel,  scissors,  or 
thermo-cautery.  At  present  we  use,  by  preference,  the 
scissors.  The  '  advantages '  ascribed  to  the  use  of  the 


INCISION  OF  THE  PORTIO  73 

cautery — lessened  haemorrhage,  illumination  of  the  field  of 
operation,  and  delay  in  the  closure  of  the  wound — will 
scarcely  be  missed  when  one  uses  the  scissors  or  knife. 

The  bleeding  from  the  first  incision  is  so  slight  that  even 
the  temporary  application  of  one  or  two  small  compression 
forceps  is  exceptional. 

We  have  already  discussed  the  questionable  advantages  of 
the  cautery  in  producing  necrosis  (p.  38). 

The  oval  form  produced  by  carrying  the  posterior  incision 
high  into  the  vaginal  vault  gives  a  much  larger  opening  than 
the  circular  incision,  which  is  equally  distant  from  the  os  at 
every  point ;  and  one  thereby  avoids  making  bleeding  lacera- 
tions of  the  vagina  during  the  enucleation  of  large  organs,  or 
in  the  freeing  of  their  upper  portions. 

Segond  has  successfully  modified  this  incision,  carrying  a 
lateral  cut  from  each  side  of  the  oval  for  a  distance  of  2  cm. 
along  and  parallel  to  the  base  of  the  broad  ligament.  The 
otherwise  closed  incision  now  results  in  the  formation  of  two 
flaps,  an  anterior  and  posterior,  similar  to  those  of  a  limb 
amputation. 

By  this  means  Segond  secures  two  advantages  :  First,  the 
field  of  operation  in  front  of  the  uterus  is  enlarged  to  its 
greatest  extent ;  and  second,  the  ureters  are  protected  in  the 
most  rational  way  from  injury  by  the  clamps,  which  he 
usually  applies  to  the  uterine  arteries  primarily.  For,  as 
will  be  shortly  explained,  this  point  depends  solely  upon  the 
extensive  and  careful  separation  of  the  bladder,  which  in- 
cludes the  freeing  of  the  ureters. 

As  a  matter  of  fact,  Paul  Segond  in  400  vaginal  operations 
for  cancer,  fibroids,  or  pelvic  suppuration,  did  not  once 
injure  the  ureters.  We  also  have  used  his  incision  with 
decided  advantage  in  difficult  cases  where  the  space  was 
limited. 

For  the  purpose  of  the  more  convenient  separation  of  the 
bladder,  we  have  abandoned  the  incision  previously  used  by 
us,  although  the  bladder  and  ureters  were  in  no  case  injured. 
To  protect  the  vessels  below  and  at  the  sides  of  the  uterus, 
and  in  the  arch  of  the  vagina,  we  formerly  left  a  bridge  of 
mucous  membrane  intact,  right  and  left  from  the  com- 


74  THE  VAGINAL  RADICAL  OPERATION 

missure  of  the  lips  of  the  cervix,  breaking  the  continuity  of 
the  oval  at  each  side.  These  were  first  incised  only  after  the 
vessels  were  clamped.  Lately  this  incision  has  been  recom- 
mended by  Condamin1,  based  upon  the  investigation  of  the 
anatomy  and  distribution  of  the  vessels  about  the  cervix  (the 
arteria  utero-vaginalis  recurrens). 

As  a  matter  of  fact,  we  still  in  many  cases  make  the  first 
incision,  anterior  or  posterior,  only  for  a  certain  distance — 
that  is,  when  we  wish  to  make  sure  of  the  indication  for  a 
vaginal  extirpation,  by  means  of  exploratory  incision  and 
direct  palpation.  This  vaginal  exploratory  incision  in  the 
anterior  or  posterior  cul-de-sac  is  employed  in  exceptional 
cases  for  diagnosis  of  inflammatory  processes,  and  much 
oftener  to  decide  whether  or  not  they  are  bilateral.  In  cases 
of  unilocular  cystic  processes  (haematocele,  retro-uterine 
abscess,  etc.),  the  exploratory  incision  is  at  the  same  time 
the  curative  operation.  We  find  the  exploratory  incision 
necessary  only  in  exceptional  cases,  because,  as  stated,  by 
proper  observation  of  the  patient,  careful  examination,  and 
the  use  of  other  diagnostic  measures  (rectal  examination, 
exploratory  puncture),  the  diagnosis  and  indication  can 
generally  be  sharply  defined  without  it.  In  suspected 
malignant  new  growth  of  the  appendages,  of  peritoneal 
tuberculosis,  or  of  congenital  malformation  of  the  internal 
sexual  organs,  we  generally  prefer  an  exploratory  incision 
through  the  abdominal  wall.  The  eye  is  here  a  valuable 
supplement  to  the  finger. 

Thus,  for  instance,  after  opening  the  belly,  the  sight  of 
nodules  upon  the  underlying  intestinal  serosa  warns  the 
operator  at  once  against  further  useless  manipulation  (peri- 
toneal tuberculosis,  disseminated  carcinoma).  If  after  the 
ventral  incision  one  wishes  to  do  a  radical  operation  on 
account  of  a  malignant  tumour  so  found,  the  eye  offers  a 
security  of  operating  through  healthy  tissues,  even  when  the 
operation  is  to  be  wholly  vaginal,  neglecting  the  primary 
exploratory  abdominal  opening. 

Whether  in  a  given  case  the  vaginal  exploratory  incision 
should  be  made  in  the  anterior  or  in  the  posterior  cul-de-sac, 

1  Condamin,  '  Lyon  Medical,'  No.  26,  June,  1895. 


INCISION  OF  THE  PORTIO  75 

depends  mainly  upon  the  situation  of  the  structures  to  be 
examined.  Therefore  we  cannot  state  that  the  one  or  the 
other  incision  is  the  one  to  be  used  in  every  case. 

Many  operators  prefer  a  longitudinal  incision  in  the 
anterior  vaginal  wall,  as-  being  the  most  satisfactory  for 
exploration.  If  it  shows  an  extirpation  of  the  uterus  to  be 
necessary,  the  oval  or  circular  cut  about  the  portio  is  at  once 
added.  We  can  hardly  recommend  this  plan,  because  every- 
thing that  can  be  palpated  can  be  reached  from  the  trans- 
verse incision  in  the  anterior  or  posterior  vaginal  vault ;  and 
because  in  hysterectomy  after  the  longitudinal  incision  the 
opening  must  be  partly  closed  again,  for  the  hole  in  the 
vagina  is  otherwise  of  alarming  extent.  As  a  general  rule, 
the  sagittal  incision  in  the  vagina  is  unnecessary  for  explora- 
tory purposes. 

Besides  this,  when  this  method  is  used,  the  bladder  must 
be  separated,  not  only  from  the  uterus,  but  from  the  anterior 
vaginal  wall  as  well,  whereas  in  cutting  transversely  across 
the  portio  in  front  the  bladder  and  anterior  vaginal  wall 
retract  in  one  piece.  In  the  one,  the  bladder  must  be 
loosened  from  two  sides  ;  in  the  other,  from  one  side  only,  and 
by  one  act. 

Apart  from  its  employment  as  an  exploratory  measure, 
however,  the  longitudinal  incision  offers  at  times  certain 
advantages  in  vaginal  hysterectomy.  Occasionally,  in  order 
to  provide  for  the  escape  of  the  secretions  through  an 
apparently  too  narrow  vaginal  aperture,  it  may  be  necessary 
to  enlarge  this  somewhat  by  splitting  the  anterior  or  posterior 
vaginal  wall  down  the  middle.  And,  further,  it  must  be 
borne  in  mind  that  in  other  vaginal  operations  a  longitudinal 
incision  reaching  quite  to  the  urethral  orifice  may  be  of  great 
service,  as,  for  instance,  in  the  extirpation  of  small  isolated 
fibroids  in  vaginal  hystero  -  myomotomy  (Doyen),  or  in 
colporrhaphy,  where  one  starts  from  the  median  longitudinal 
incision  and  conveniently  dissects  and  excises  two  sym- 
metrical lateral  flaps.  From  this  it  is  evident  that  the 
longitudinal  incision  is  serviceable  in  certain  cases  of  vaginal 
hysterectomy,  where  at  the  same  time  it  is  necessary  to 
resect  a  portion  of  the  superabundant  vaginal  wall.  Such 


76  THE  VAGINAL  RADICAL  OPERATION 

are  cases  in  which  the  uterus  requires  removal  on  account  of 
prolapse  of  uterus  and  vagina,  or  in  which  vaginal  hyster- 
ectomy is  performed  for  myoma,  double  pyosalpinx,  etc.,  and 
a  marked  hypertrophy  of  the  vaginal  tissues  requires  to  be 
remedied  at  the  same  time. 

Finally,  one  may  be  compelled  to  proceed  with  the  extir- 
pation of  the  womb  after  beginning  with  the  longitudinal 
incision  for  the  purpose  of  hystero-myomotomy,  and  finding 
to  one's  surprise  bilateral  disease  of  the  adnexa,  or  grave 
changes  in  the  uterus  itself,  calling  for  a  radical  operation. 
Here  the  usual  oval  incision  must  be  joined  to  the  sagittal 
cut,  and  after  the  operation  is  finished  the  latter  must  be 
sutured  again.  Or,  to  stick  to  the  clamps,  one  may  narrow 
the  too-broad  opening  by  bringing  the  edges  of  the  linear 
wound  together  by  applying  light  clamps  thereto. 

That  the  first  incision  is  in  no  way  prejudicial  to  the 
radical  operation  is  evident.  The  objection  that  the  vaginal 
operations  are,  as  a  rule,  more  mutilating  than  the  abdominal 
does  not  apply  at  all  to  the  incisions  with  which  the  opera- 
tion is  begun,  since  this  latter  may  be  brought  to  a  close 
directly  afterwards  if  desired.  It  seems  to  be  forgotten  that 
the  vaginal  incision  has  become  the  initial  stage  of  special 
and  systematic  conservative  methods  of  extirpation,  which 
are  older  than  the  methodical  hysterectomy. 

Atlee  (1859),  Battey  (1869),  T.  Gaillard  Thomas  (1870), 
R.  Davis  (1872),  J.  T.  Gilmore  (1873),  E.  Clifton  Wing 
(1876),  Goodell  (1876),  and  others,  removed  ovarian  tumours, 
tubal  pregnancy,  unilateral  pus-tubes,  etc.,  through  the  trans- 
verse or  longitudinal  posterior  incision,  sparing  the  uterus 
and  the  healthy  adnexa.1 

Now  that  this  operation  is  being  recommended  and 
practised  under  the  modern  names  of  colpotomy,  vaginal 
cceliotomy,  vaginal  laparotomy,  etc.,  these  authors  deserve 
at  least  the  credit  of  having  refuted  the  objection  to  the 
vaginal  operation — that  after  it  is  once  begun  there  is  no 
turning  back. 

1  Armand  Bonnecaze,  Paris,  1889,  Inaugural  Dissertation. 


FREEING  OF  THE  UTERUS  77 

THIRD  STAGE  :  FREEING  THE  UTERUS  FROM  THE  PERI- 
CERVICAL  TISSUE — THE  ANATOMICAL  RELATIONS  OF 
THE  BLADDER  AND  URETERS  TO  THE  GENITAL 
ORGANS. 

The  separation  of  the  uterus  from  the  pericervical  tissue, 
through  the  oval  incision,  is  performed  either  by  cutting  with 
the  knife  or  scissors,  or  by  blunt  dissection  with  the  finger, 
or  raspatory,  using  the  scalpel  handle  for  this  purpose.  As 
a  rule,  we  begin  posteriorly,  pushing  the  loose  perirectal 
cellular  tissue  away  from  the  cervix,1  when  the  primary 
incision  has  not  already  opened  the  posterior  pouch  of 
Douglas,  giving  free  entry  into  the  abdomen.  Otherwise 
it  is  necessary  to  bore  through  a  variable  depth  of  retro- 
cervical  tissue  before  reaching  the  posterior  fold  of  peri- 
toneum ;  the  opening  of  the  peritoneal  cavity  is  frequently 
completed  at  the  same  time.  In  the  uncomplicated  cases 
now  under  consideration,  an  injury  of  the  intestine  is 
impossible. 

At  other  times  the  peritoneum  recedes ;  then  we  do  not 
spend  much  time  in  the  attempt  to  get  through  at  this  point, 
but  begin  at  once  in  front  and  at  the  sides  of  the  cervix. 
The  bladder  is  pushed  well  up  out  of  its  loose  connective- 
tissue  bed,  as  thoroughly  and  carefully  at  each  side  as  in  the 
middle. 

In  freeing  the  uterus,  the  separation  of  the  connective 
tissue  about  the  cervix  is  combined  with  a  gradually- 
increasing  traction  downwards,  by  means  of  the  volsellse 
applied  to  the  portio.  If  one  works  in  the  proper  strata, 
i.e.,  behind  in  the  loose  perirectal  cellular  tissue,  and  in 
front  in  the  yielding,  easily-separable  layer  connecting  the 
bladder  and  cervix,  the  loosening  of  the  uterine  neck  from 
bladder  and  rectum  occurs  in  these  cases  almost  of  its  own 
accord,  aided  merely  by  the  downward  traction.  Small 
resisting  bands  are  encountered  in  the  perivaginal  tissue, 

1  Other  operators  besides  ourselves  have  observed  a  peculiar  reflex 
moaning  which  occurs  during  the  loosening  of  the  perirectal  tissue, 
even  in  the  deepest  narcosis  ;  at  times  also  during  the  denudation  of  the 
bladder. 


78  THE  VAGINAL  RADICAL  OPERATION 

connecting  the  vaginal  mucous  membrane  with  the  paren- 
chyma of  the  uterus ;  they  are  simply  to  be  cut  through 
with  the  scissors.  At  times  small  muscular  bundles  are  also 
found  here,  passing  from  the  superficial  muscular  layer  of 
the  uterus  to  anastomose  with  the  longitudinal  bands  on  the 
posterior  surface  of  the  bladder.  As  Luschka  has  demon- 
strated, they  leave  the  uterus  in  the  region  of  the  internal 
os  ;  some  may  be  traced  as  far  as  the  urethro-vaginal  septum. 

The  vagina  so  loosened,  together  with  its  submucosa,  is 
rolled  upwards  by  the  lifting  movements  of  finger  and 
retractor.  The  retractor  serves  in  front  especially  to  pro- 
tect the  bladder  and  ureters,  and  also  as  an  active  aid  to  the 
finger  and  raspatory  in  the  process  of  separation. 

One  works  here  always  against  the  uterus,  exactly  as  in 
raising  the  periosteum  from  a  bone.  In  all  these  manipula- 
tions, especially  where  the  space  is  limited,  the  removal  of 
the  retractors  or  ecarteurs  partly  or  wholly  from  the  vagina 
from  time  to  time  is  often  a  great  help  during  the  liberation 
of  the  cervix.  In  this  way  the  operator's  finger  is  not 
unnecessarily  hindered  by  the  instruments ;  and  by  lifting, 
depressing,  or  turning  the  forceps  on  the  cervix  one  may 
correspondingly  enlarge  the  space  in  which  he  is  working. 

There  is  no  haemorrhage  during  the  separation  of  the 
cervix  if  the  dissection  is  made  as  much  as  possible  bluntly, 
and  if,  in  loosening  the  bladder,  one  does  not  get  too  deep 
into  the  lateral  tissues  (arteria  uterina).  In  front,  on  the 
bladder,  no  vessels  worth  mentioning  are  divided,  and  there 
are  no  important  anastomoses  between  the  vesical  and 
uterine  vessels.  A  possible  parenchymatous  oozing  from  the 
vascular  layer  of  the  perirectal  tissue  may  always  be  safely 
neglected  until  the  extirpation  of  the  organs  has  been  com- 
pleted, because  the  pressure  of  the  uterus  as  it  is  drawn 
down  controls  the  bleeding,  just  as  a  tampon  would. 

Injury  to  the  bladder  and  ureters  will  be  avoided  if  the 
rules  above  given  for  the  incision  are  observed — that  is, 
to  keep  as  close  as  possible  to  the  external  os  in  front 
and  at  the  sides.  In  like  manner,  during  the  liberation 
of  the  cervix,  these  structures  must  be  so  removed  from 
the  field  of  operation  that  during  the  succeeding  stages 


RELATIONS  OF  THE  BLADDER  AND  URETERS         79 

(clamping  and  resection),  they  remain  protected  from  every 
injury,  and  do  not  really  come  into  view  again.  With  this 
task  fulfilled,  one  of  the  most  dangerous  reefs  in  the  vaginal 
hysterectomy  has  been  successfully  navigated. 

The  significance  of  the  incisions  recommended,  and  the 
above-described  manner  of  freeing  the  cervix,  depends  of 
course  on  the  anatomical  relations  existing  between  the 
urinary  and  genital  organs.  We  may  here  suitably  refer 
to  two  points,  whose  importance  does  not  seem  to  be 
sufficiently  recognised  by  many  writers. 

First,  the  lateral  portions  of  the  bladder,  even  when  the 
organ  is  empty,  do  not  correspond  to  the  limits  of  the  cervix, 
but  rest  on  both  sides  upon  the  lower  median  portions  of 
the  broad  ligament,  loosely  connected  with  this  ligament 
and  the  paravaginal  cellular  tissue  beneath  it.1  The  neck 
of  the  womb  is  covered  by  the  bladder  in  the  lower  two- 
thirds  of  its  supravaginal  portion  (Luschka),  and  to  a  still 
greater  extent  when  the  latter  organ  is  much  distended. 

Secondly,  each  ureter  from  its  point  of  entrance  into  the 
bladder  is  for  about  5  cm.  toward  the  kidney  in  such 
intimate  relation  with  the  posterior  vesical  wall  that  every 
displacement  of  the  organ  moves  this  segment  of  the  ureter 
directly  with  it.  To  use  a  definite  anatomical  expression, 
this  association  of  these  two  structures  begins  just  where 
the  ureter  in  its  forward  course  crosses  the  pelvic  end  of  the 
broad  ligament.  This  whole  portion,  5  cm.  long,  lies  between 
the  bladder  wall  and  the  paracervical,  parafornical,  and 
paravaginal  structures  respectively. 

From  this  point  of  view,  the  division  of  the  ureter,  as  it  is 
given  by  the  anatomists  (a  pars  abdominalis  14  cm.  long 
from  the  kidney  to  the  inlet  of  the  true  pelvis,  a  pars  pelvica 
12  cm.  long,  passing  across  the  true  pelvis  to  enter  the 
vesical  musculature,  and  a  pars  vesicalis,  the  portion  within 
the  bladder  wall),  deserves  a  certain  modification  for  the 
surgeon  in  reference  to  its  second  and  third  divisions.  For 
him  the  pars  pelvica  ceases  at  the  point  where  the  ureter, 
coming  from  the  base  of  the  broad  ligament,  approaches  the 

1  A.  Mackenrodt,  '  Zeitschrift  f.  Geburtshiilfe  und  Gynak.,'  Bd.  29, 
p.  157. 


8o  THE   VAGINAL  RADICAL  OPERATION 


bladder,  to  become  intimately  joined  with  this  organ.  The 
true  vesical  portion  begins  here.  Accordingly,  the  female 
ureter,  26  cm.  long,  may  for  surgical  purposes  be  divided 
into  an  abdominal  portion  14  cm.,  a  pelvic  portion  7  cm., 
and  a  vesical  portion  5  cm.  in  length. 

From  the  foregoing,  it  follows  that  when  the  bladder, 
together  with  the  vaginal  wall,  is  to  be  lifted  up  in  its 
entirety,  one  must  not  be  content  with  merely  severing  the 
loose  connection  with  the  cervix,  but  the  dissection  must  be 
extended  laterally  to  the  broad  ligaments  and  the  para- 
vaginal  connective  tissue.  In  freeing  the  bladder,  the  only 
fixed  point  is  the  vesical  neck,  i.e.,  the  place  of  transition 
from  bladder  into  true  urethra,  while  in  all  other  portions 
the  connections  of  these  organs  are  unusually  weak.  Only 
in  the  region  of  the  trigone  is  the  bladder  somewhat  more 
firmly  united  with  the  vagina. 

It  follows,  further,  that  when  the  bladder  is  completely 
raised  up,  the  vesical  portion  of  the  ureter,  according  to  our 
designation,  must  also  take  part  in  this  dislocation.  The 
freeing  of  the  bladder,  which  is  characterized  by  some 
writers  as  a  special  stage  in  vaginal  hysterectomy,  is  there- 
fore not  only  a  separation  of  the  bladder  from  the  uterus, 
but  is  in  a  wider  sense  the  disconnection  of  the  bladder, 
together  with  the  vesical  portion  of  the  ureters,  from  the 
uterus,  and  from  the  main  portion  of  the  broad  ligaments 
as  well  as  from  the  cardinal  ligaments  and  the  paravaginal 
tissues. 

On  account  of  the  importance  of  the  anatomical  relations 
between  the  urinary  and  genital  organs  in  their  bearing  on 
the  vaginal  radical  operation,  we  deemed  it  advisable  to 
investigate  the  matter  by  dissections  and  experiments  on  the 
cadaver.  The  following  is  a  resume  of  the  conclusions  derived 
from  our  experiments. 

In  looking  at  the  course  of  the  ureters,  one  notices  first  the 
pars  abdominalis,  having  the  form  of  an  italic/,  lying  in  the 
loose  retro-peritoneal  cellular  tissue  upon  the  psoas  muscles, 
converging  from  the  outer  towards  the  inner  edge  as  they 
descend.1 

1  Compare    Luschka,  '  Topogr.    d.   Harnleiter  des  Weibes,'  'Arch.  f. 
Gynakol.,'  Bd.  3,  p.  373  et  seq. 


RELATIONS  OF  THE  BLADDER  AND  URETERS          81 

Then  comes  the  pelvic  portion  as  above  defined ;  this 
portion  of  the  ureter,  lying  close  up  against  the  lateral  wall 
of  the  true  pelvis  on  each  side,  describes  a  shallow  curve 
with  the  convexity  outwards  and  backwards,  the  left  to  the 
inside,  the  right  to  the  outside  of  the  hypogastric  artery. 
The  curve  reaches  to  the  base  of  the  broad  ligament  (lig. 
cardinale),  and  then  turning  more  to  the  front  and  towards 
the  middle  line,  passes  through  the  loose  connective  tissue 
at  the  pelvic  end  of  this  ligament.  Immediately  after  this, 
on  a  level  with  the  base  of  the  broad  ligament,  it  is  crossed  by 
the  round  ligament,  which  courses  away  from  it ;  close  by, 
and  in  the  same  horizontal  plane,  it  passes  over  the  larger 
uterine  vessels  (uterine  artery  and  plexus  of  veins),  and  at 
once  enters  the  posterior  wall  of  the  bladder,  which,  as  above 
stated,  extends  laterally  on  to  the  parafornical  and  para- 
cervical  tissues.  The  ureter  is  here  intimately  connected 
with  the  vesical  wall,  as  the  pars  vesicalis  of  our  descrip- 
tion. 

Thus  the  ureter,  descending  from  the  level  of  the  infundi- 
bulo-pelvic  ligament  obliquely  inwards,  does  not  traverse  the 
whole  central  connective-tissue  portion  of  the  broad  ligament 
in  a  straight  line,  as  one  might  conclude  by  looking  at 
dissection  of  these  structures  when  spread  out  flat. 

How  is  this  to  be  reconciled  with  the  observation  made 
by  Luschka  that  the  distance  between  the  converging  ab- 
dominal segments  of  the  ureters  becomes  greater  again 
in  the  true  pelvis ;  that  at  a  certain  point,  namely  at  the 
level  of  the  fourth  sacral  vertebra,  the  separation  amounts 
to  2.\  cm.  more  than  at  the  renal  end,  the  ratio  being  nj  to 
9  cm.  ? 

It  is,  however,  more  to  the  purpose  to  emphasize  the  fact 
that  the  ureter  passes  through  the  connective  tissue  only  at 
the  outer  end  of  the  base  of  the  broad  ligament,  and,  apart 
from  this,  has  nothing  to  do  with  the  connective  tissue  in 
the  whole  height  and  extent  of  its  central  portions. 

Since  the  pars  pelvica,  immediately  after  piercing  the 
ligament,  becomes  the  pars  vesicalis,  it  follows  that  every 
displacement  of  the  bladder  with  the  vesical  portion  of  the 
ureters  must  affect  the  pelvic  portions  as  far  as  their  course 

6 


82 


THE  VAGINAL  RADICAL  OPERATION 


lies  within  the  loose  connective  tissue  of  the  base  of  the 
broad  ligaments. 

Accordingly,  in  raising  the  bladder  properly,  the  fixed 
point  of  the  ureters  lies  beyond  the  point  where  they  pass 
through  the  base  of  the  broad  ligament,  i.e.,  on  the  wall  of 
the  true  pelvis,  on  the  side  of  the  ligament  nearer  the  kidney. 
The  distance  of  this  fixed  point  from  the  uterus,  when 


FIG.  19. — DIAGRAM  OF  THE  COURSE  OF  THE  URETERS  (LUDVVIG  PICK). 

a  b  Abdominal  portion  =  14  cm.  ;  b  c  pelvic  portion  =  7  cm.  ;  c  d  vesical  portion 
=  5  cm.  :  c  indicates  the  point  of  entrance  of  the  ureter  into  the  most 
lateral  portion  of  the  broad  ligament. 

measured  transversely,  is  therefore  the  same  as  the  whole 
breadth  of  the  broad  ligament,  or  about  5  cm.  on  each  side. 

In  view  of  this,  one  may  say  that  the  bladder  and  ureters, 
after  their  entry  into  the  true  pelvis,  and  the  genitalia  with 
the  broad  ligaments  and  vessels,  represent  two  independent 
and  displaceable  systems,  separated  from  each  other  by  a 


RELATIONS  OF  THE  BLADDER  AND  URETERS         83 

connective-tissue  layer,  which  is  easily  separated  throughout 
its  whole  extent.  The  two  systems  are  arranged  in  the  transverse 
plane,  panel-like,  one  behind  the  other.  The  complete  elevation  of 
the  bladder,  especially  of  its  lateral  portions,  includes  also  the 
complete  freeing  of  the  ureters  up  to  the  wall  of  the  true  pelvis, 
thereby  giving  a  field  of  operation  on  each  side  of  the  uterus,  cor- 
responding to  the  whole  width  of  the  broad  ligaments. 

When  in  an  operation  the  two  systems  have  once  been 
separated  from  each  other  by  means  of  downward  traction 
upon  the  genitalia  and  their  ligaments,  and  by  pushing  the 
bladder  and  ureters  upwards,  it  is  only  necessary  to  main- 
tain this  artificial  position  by  means  of  retractors  or  similar 
instruments,  to  insure  against  injury  of  the  urinary  apparatus 
during  the  further  stages  of  the  operation  (separation  and 
resection  of  the  internal  genital  organs). 

Experience  teaches  that  even  in  the  most  thorough  denu- 
dation of  bladder  and  ureters,  we  need  have  no  fear  of 
disturbance  of  their  innervation  or  blood  supply.  That  this 
freeing  of  the  bladder  is,  however,  not  always  a  harmless  act 
is  shown  by  certain  cases  in  which  haematuria  occurs  or 
retention  persists  for  days  after  the  operation,  attributable, 
in  part  at  least,  to  direct  injury  of  the  muscles  or  nerves  of 
the  organ. 

But,  on  the  other  hand,  the  fact  that  nowhere  has  gan- 
grene or  any  severe  lasting  functional  disturbance  of  the 
urinary  apparatus  been  observed  after  this  severe  vaginal 
operation,  is  explained  by  the  circumstance  that  the  anterior 
relations  of  the  bladder  are  not  interfered  with,  and  the  rest  of 
its  circumference  is  provided  with  a  relatively  thick  layer  of 
connective  tissue  which  contains  its  nerves,  and  the  vessels 
springing  from  the  vasa  hypogastrica. 

That  the  anterior  surface  of  this  organ  may  also  be  partly 
freed  from  its  connections  without  any  nutritive  or  functional 
injury  to  it,  is  shown  by  the  results  of  uterine  extirpation 
when  begun  with  the  longitudinal  incision  in  the  anterior 
vaginal  wall. 

After  the  ureter  crosses  the  pericervical  plexus  of  veins, 
and  passing  over  the  art.  uterina,  joins  the  posterior  bladder 
wall,  its  further  course,  the  pars  vesicalis,  takes  the  form  of  a 

6—2 


84  THE   VAGINAL  RADICAL  OPERATION 

shallow  double  curve  along  the  supravaginal  portion  of  the 
cervix,  and  approaches  the  vaginal  vault  (Fig.  19).  Steadily 
nearing  this  structure,  it  crosses  over  the  anterior  vaginal 
wall  at  a  sharp  angle  on  a  level  with  the  deepest  portion  of 
the  portio  at  each  side.  This  point  is  about  at  the  junction 
of  the  upper  part  of  the  vagina  and  the  vaginal  vault.  Here 
the  ureters  course  along  the  front  vaginal  wall  at  each  side, 
wedged  in  between  it  and  the  bladder  for  a  distance  of 
i£  cm.,  to  reach  their  orifices  at  the  angle  of  the  trigone 
2|  cm.  apart.  If  these  orifices  were  projected  on  to  the  vaginal 
wall,  they  would  fall  at  the  junction  of  the  middle  and  upper 
thirds  of  the  vaginal  canal.  The  distance  of  the  vesical 
portions  from  the  cervix  on  each  side,  at  the  place  where 
they  approach  nearest  to  it,  is  about  i^  cm. 

When  the  mobile  uterus  is  drawn  down  into  the  vagina 
by  traction  on  the  portio,  the  bladder  and  ureters  suffer  a 
certain  displacement  as  well  as  the  uterus  itself.  The  pos- 
terior and  lower  bladder-wall  forms — as  is  easily  shown  by 
introducing  a  catheter — a  cystocele,  whose  size  varies  with 
the  case  ;  the  converging  ureters  are  brought  nearer  to  the 
cervix  because  the  lower  segment  of  the  uterus  increasing  in 
thickness  from  below  upwards  is  drawn  in  between  them  like 
a  wedge.  The  dislocation  of  the  bladder  and  ureters  by  traction 
on  the  womb  is  relatively  much  smaller  than  that  of  the  uterine 
neck.  The  cervix  is  really  wedged  in  between  the  ureters, 
which  from  the  downward  traction  are  more  or  less  on  a 
stretch  up  to  the  pelvic  wall.  When  the  vaginal  vault  and 
the  portio  are  drawn  into  the  entrance  of  the  vagina,  or  even 
beyond  the  vulva,  far  below  the  level  of  the  vesical  orifices 
of  the  ureters,  those  portions  of  these  ducts  in  relation  to 
the  vagina  up  to  their  junction  with  the  bladder  assume  a 
horizontal  or  even  ascending  direction. 

In  any  case,  when  the  normal  mobile  uterus  is  pulled 
downward,  the  bladder  and  vesical  portions  of  the  ureters 
must  be  brought  closer  to  each  other  in  the  anterior  vaginal 
vault.  Hence  upon  these  considerations  is  based  the  rule 
to  keep  the  primary  incision  close  to  the  external  os  in  front  and — 
for  safety's  sake — at  the  sides  also,  while  posteriorly  it  may 
extend  far  into  the  vaginal  vault.  If  the  incision  is  carried 


RELATIONS  OF  THE  BLADDER  AND   URETERS          85 

too  far  from  the  os  externum,  the  ends  of  the  anterior  curve 
may  strike  the  ureters  while  the  middle  may  reach  the 
bladder. 

When  the  womb  is  fixed  and  cannot  be  pulled  down,  the 
bladder  and  ureters  naturally  remain  in  place.  Here  the 
danger  of  injury  to  the  bladder  lies  in  the  primary  incision 
in  the  anterior  vaginal  vault.  The  ureters,  lying  along  the 
lateral  fornices  of  the  vagina,  are  also  in  danger,  especially 
since  they  may  be  drawn  still  closer  to  the  cervix  by  reason 
of  paracervical  indurations  and  cicatrices.1 

1  Recent  statistics  refer  to  the  right  ureter  being  more  frequently  injured 
in  vaginal  hysterectomy  than  the  left.  The  material  is  so  slight  that  it 
is  not  impossible  that  this  preponderance  is  merely  accidental  ;  still,  a 
number  of  explanations  have  been  offered.  Tuffier  ascribes  the  cause 
to  the  inconvenience  of  applying  the  clamps  to  the  right  side,  the  instru- 
ments being  pushed  too  far  over,  and  so  injuring  the  ureter. 

Fournel,  from  several  observations,  bases  his  explanation  upon 
mechanical  grounds.  First,  the  operator's  left  hand  pulling  on  the 
volsellae  always  deviates  unconsciously  from  the  middle  line,  leaving  the 
side  of  the  bladder  and  the  corresponding  ureter  to  retract  from  the 
enucleating  finger.  Secondly,  the  left  hand,  in  a  position  midway  between 
pronation  and  supination,  inclines  of  itself  to  supination,  turning  the  right 
side  of  the  uterus  and  the  right  ureter  still  further  away  from  the  finger 
which  is  loosening  bladder  and  ureter  from  the  uterus. 

Fournel's  opinion  that  the  relations  of  the  ureters  to  the  cervix  on  each 
side  are  the  same,  is  hardly  correct. 

The  distance  of  the  ureters,  not  only  from  the  cervix  but  from  the 
uterus  itself,  varies,  and  while  the  difference  is  so  slight  that  it  has  but 
little  importance  for  the  rules  governing  the  isolation  of  the  urinary 
organs,  still,  from  the  anatomical  standpoint  it  is  worthy  of  notice. 
Luschka  says,  '  Since  there  is  a  slight  but  pronounced  deviation  of  the 
long  axis  of  the  uterus  from  the  imaginary  median  plane  of  the  pelvis, 
which  is  normal  and  dependent  upon  the  position  of  the  rectum,  it  must 
follow  that  one  of  the  ureters  will  be  closer  to  the  uterus  than  the  other. 
On  account  of  the  rectum  being  to  the  left,  the  deviation  of  the  uterus  is 
most  frequently  to  the  right,  bringing  it  nearer  to  the  corresponding 
ureter.  In  the  exceptional  course  of  the  rectum  downward,  from  right  to 
left,  the  relations  are  usually  reversed.'  According  to  this  the  right  ureter 
is  the  more  liable  to  injury  when  the  bladder  and  ureters  have  not  been 
sufficiently  isolated,  especially  in  prophylactic  clamping. 

Further,  Luschka  emphasizes  the  fact  '  that  the  distance  of  the  ureters 
from  the  uterus  must  vary  with  the  physiological  condition  of  that  organ,' 
and  it  is  evident  that  cicatricial  peri-  and  para-metritic  processes,  as  well 


86 


FOURTH  STAGE  :  OPENING  THE  PERITONEAL  CAVITY. 

If  it  is  merely  an  exploratory  incision,  the  anterior  or 
posterior  cul-de-sac,  and  the  anterior  or  posterior  reflection  of 
the  peritoneum,  must  be  opened  after  making  the  vaginal 
incision,  according  to  the  position  of  the  organs  or  structures 
to  be  palpated,  whether  situated  in  front  of  or  behind  the 
uterus. 

The  first  cut  with  the  scissors  in  the  posterior  vaginal 
vault  often  opens  up  the  pouch  of  Douglas  at  the  same  time, 
or  the  finger  pushing  aside  the  peri-rectal  cellular  tissue  bores 
at  once  through  the  thin  peritoneal  membrane.  When  this, 
which  is  often  only  too  elastic,  recedes  before  the  finger,  a 
small  fold  must  be  caught  up  with  forceps  or  pincette  and 
pulled  down  so  that  it  can  be  opened  transversely  with  the 
point  of  the  scissors.  The  small  wound  is  then  widened  by 
the  finger  as  much  as  may  be  necessary. 

If  the  exploratory  incision  is  to  be  made  in  front,  whether 
it  be  transverse  or  sagittal,  the  bladder  and  ureters  must  first 
be  raised  completely  out  of  the  field  of  operation.  The 
anterior  fold  of  peritoneum  (plica  vesico-uterina)  appears  at 
once  as  a  thin  shiny  bluish-white  membrane  when  normal,  or 
in  case  of  perimetritis  as  a  thicker  white  tissue  which,  as  in 
the  posterior  cul-de-sac,  extends  on  to  the  uterus  for  a  variable 
distance.  The  peritoneum,  as  it  comes  into  view  in  the 
middle  line,  is  best  opened  transversely,  the  scissors  cutting 
directly  against  it ;  the  closed  scissors  are  then  pushed  into 
the  small  hole  so  made,  and  this  torn  widely  open  by  spread- 
ing the  handles  (Fig.  20).  The  upper  part  of  the  fold 
follows  the  bladder,  and  of  its  own  accord  retracts  out  of  the 
field  of  operation.  The  finger  is  now  introduced  through  the 
opening,  along  the  front  wall  of  the  uterus  into  the  abdominal 
cavity. 

as  pathological  changes  in  the  form  of  the  uterus  from  tumours,  etc., 
must  alter  its  relations  to  the  ureters. 

Still,  after  allowing  the  fullest  recognition  to  these  individual  relations, 
the  fundamental  principle  for  freeing  the  bladder  remains  unchanged  ; 
viz.,  the  most  complete  elevation  of  the  organ  in  the  middle  as  well  as  at 
the  sides. 


OPENING  OF  THE  PERITONEAL  CAVITY  87 

No  matter  where  the  exploratory  incision  is  made,  whether 
in  front  or  behind,  there  is  no  important  haemorrhage  en- 
countered either  in  freeing  the  pericervical  tissues  or  in 
boring  through  the  peritoneum. 


FIG.  20. — INTRODUCTION  AND  SPREADING  OF  THE  SCISSORS  IN  OPENING  THE 
UTERO-VESICAL  POUCH. 

The  opening  of  the  peritoneum  is  made  in  exactly  the 
same  way  in  a  hysterectomy  previously  intended,  as  in  one 
which  is  decided  upon  after  exploratory  incision,  except  that 
when  the  finger  cannot  bore  through  the  posterior  cul-de-sac 
at  once,  the  incision  in  front  through  the  plica  vesico-uterina 
must  alone  suffice  for  the  time  being. 


88  THE  VAGINAL  RADICAL  OPERATION 

The  pouch  of  Douglas  is  then  opened  only  after  the  next 
stage  of  the  operation  has  been  completed,  i.e.,  the  separa- 
tion of  the  internal  genital  organs. 

FIFTH  STAGE  :  LUXATION  OF  THE  UTERUS  AND  ADNEXA 
INTO  THE  VAGINA. 

Directly  after  opening  the  anterior  plica,  a  retractor  is 
introduced  which  guards  the  bladder  and  ureters  and  carries 
the  anterior  peritoneal  fold  well  up  over  the  fundus  of  the 
uterus,  so  that  we  have  no  more  trouble  with  it  during  the 
rest  of  the  operation.  One  or  two  volsellae  are  fixed  perpen- 
dicularly into  the  middle  line  of  the  body  of  the  uterus,  close 
to  the  fundus,  and  the  womb  is  now  anteflexed  as  much  as 
possible  by  one  or  two  fingers  introduced  through  the 
posterior  cul-de-sac  or,  when  this  is  still  unopened,  pressed 
high  up  against  the  uterus  posteriorly. 

By  this  combination  of  pressure  from  behind  and  traction 
on  the  forceps  in  front,  the  uterus  is  easily  drawn  out  of  the 
pelvic  cavity ;  the  organ  slips  through  the  \vound  in  the 
anterior  vaginal  wall  like  a  foot  out  of  a  shoe. 

The  dislocated  uterus  now  lies  quite  free  in  the  vagina, 
often,  indeed,  in  the  vulva,  with  its  posterior  surface  braced 
against  the  symphysis,  held  above  and  at  the  sides  by 
the  broad  ligaments  as  by  elastic  bands  (Fig.  21).  Pro- 
lapse of  intestine  or  omentum  is  hindered  by  the  retractor, 
and  by  a  quickly  arranged  slight  degree  of  pelvic  eleva- 
tion. 

Sometimes,  when  the  space  is  limited,  it  is  necessary  to 
remove  the  retractor  in  front,  and  the  finger  from  the 
posterior  cul-de-sac.  In  such  cases  the  traction  on  the  front 
wall  of  the  uterus  may  be  supplemented  with  good  effect  by 
pushing  the  portio  backwards  and  upward  by  means  of  the 
forceps  which  are  still  attached  to  it.  After  the  womb  has 
been  so  brought  forward,  the  front  retractor  is  to  be  intro- 
duced again  above  and  behind  the  uterus,  since  it  forms  the 
chief  protection  to  the  bladder  and  intestines  during  the 
whole  course  of  the  operation. 

The  use  of  the  volsellae  in  drawing  the  uterus  forward  is 


LUXATIOX  OF  THE   UTERUS 


89 


much  to   be  preferred  to  the  silk  sutures  or   sharp  hooks 
generally   employed   for   this   purpose.     When    the   uterine 


FIG.  21. — EVULSION  OF  THE  FUNDUS  FROM  THE  PELVIC  CAVITY. 

parenchyma  is  soft  and  brittle,  it  is  sometimes  advisable  to 
lift  the  organ  out  by  means  of  a  hook  fixed  into  it,  and  a 


90  THE  VAGINAL  RADICAL  OPERATION 

short  retractor  passed  over  the  fundus  on  to  the  posterior 
surface. 

If  the  posterior  cul-de-sac  has  not  been  opened,  the  peri- 
toneal fold  is  now  to  be  severed  from  above,  preferably  by 
pushing  a  light  clamp  forceps  through  it — a  method  which  is 
absolutely  without  danger  to  the  adjacent  organs.  The 
points  of  the  clamp  are  meanwhile  guarded  by  a  finger  intro- 
duced behind  the  fundus  from  above,  and  by  one  passed 
into  the  posterior  vaginal  incision  (Fig.  22). 

Now  that  the  womb  has  been  completely  dislocated  for- 
wards, the  tubes  and  ovaries,  sometimes  healthy,  some- 
times diseased,  are  visible  ori  its  posterior  surface  at  each 
side. 

If  the  anteflexion  of  the  uterus  be  increased  by  slight 
traction,  one  can  frequently  see  the  adnexa  as  far  as  the 
infundibulo-pelvic  ligament,  and  they  can  thus  be  freed  and 
brought  out  into  the  vagina.  They  may  be  secured  by 
passing  the  finger  along  the  isthmus  of  the  tubes,  or  equally 
well  with  the  ovarian  forceps  (Fig.  9),  whose  pressure  is 
spread  over  a  large  surface,  and  whose  elastic  blades  do  not 
crush  the  tissues  (Fig.  23). 

When  the  appendages  are  fixed  the  adhesions  must  be 
separated  first  of  all.  For  this  the  introduction  of  one 
(index)  or  two  (middle  and  index)  fingers  suffices  to  shell  out 
and  liberate  the  ovaries  and  tubes. 

For  the  extraction  of  tumours  of  the  adnexa  it  is  often 
advisable  to  pass  one  or  two  fingers  of  each  hand  into  the 
abdomen.  These  grasp  the  tumour  as  the  forceps  do  the 
child's  head  in  obstetrics,  and  deliver  it  with  the  least 
possible  injury  to  its  structure.  The  liberated  portions  of 
the  appendages  as  they  come  into  the  field  are  seized,  secured 
and  drawn  down  with  ovarian  forceps,  without  using  too 
much  force. 

Bimanual  manipulations,  such  as  are  employed  in  the  usual 
gynaecological  examination,  one  hand  inside  and  one  on  the 
abdomen,  are  superfluous  in  the  simple  cases  now  under 
discussion. 

When  the  uterus  is  mobile  it  is  easy  to  pull  it  through  the 
slit  in  the  posterior  vaginal  vault  by  retroflexing  it  strongly, 


LUXATION  OF  THE  UTERUS 


but  as  a  rule  we  prefer  to  dispense  with  this  procedure.  If 
it  is  to  be  employed,  the  womb  must  first  be  most  carefully 
freed  from  its  connection  with  the  bladder  and  ureters,  since 


FIG.    22. — OPENING   THE    POUCH   OF    DOUGLAS    BY    THRUSTING  A  FORCEPS 
THROUGH  FROM  ABOVE. 

otherwise  a  backward  dislocation  of  the  organ  might  cause  a 
laceration  of  the  bladder. 

The  procedure  may  be  employed,  for  instance,  where  it  is 
necessary  to  extirpate  a  uterus  whose  portio  is  absent,  in 
which  case,  to  protect  the  adjacent  organs  as  much  as 


92  THE  VAGINAL  RADICAL  OPERATION 

possible,  one  has  to  begin  the  operation  by  attacking  the 
posterior   uterine  wall  with  volsellae  and  scissors ;    also  in 


FIG.  23.  —  UTERUS,  WITH  THE  APPENDAGES  OF  BOTH  SIDES,  DRAWN  DOWN 
INTO  THE  VAGINA  ;  THE  RIGHT  APPENDAGES  SEIZED  WITH  AN  OVARIAN 
FORCEPS. 

cases  where  an  extreme  degree  of  retroflexion  with  fixation 
is  present ;  and,  finally,  in  posterior  hemi-section  of  the 
uterus,  which  will  be  described  later. 


LUXATION  OF  THE   UTERUS  93 


Even  after  the  uterus  and  its  appendages  have  been 
luxated  into  the  vagina,  the  fate  of  the  internal  genitalia,  so 
brought  out  of  the  abdomen  for  direct  examination  by  sight 
and  touch,  is  but  little  prejudiced.  After  possible  adhesions 
about  the  tubes  and  ovaries  have  been  severed,  and  cysts  in 
the  ovary  or  in  the  peritonitic  adhesions  punctured  and 
evacuated,  the  operation  can  be  suspended  at  this  point 
exactly  as  in  a  vaginal  coeliotomy,  regardless  of  the  more 
extensive  denudation  of  the  cervix  just  performed.  The 
womb  and  appendages  may  be  replaced,  just  as  a  dislocated 
limb  is  reduced,  for  up  to  this  time  none  of  the  larger  vessels 
have  been  cut  off.  One  or  both  appendages  may  be  operated 
upon  or  extirpated  when  inflammatory  processes,  tubal 
pregnancy,  or  small  tumours  are  present.  Myomata  can 
be  shelled  out  of  the  uterine  parenchyma,  or  other  plastic 
operations  may  be  done  on  the  adnexa,  such  as  resection  of 
the  ovary,  salpingectomy,  etc.  Finally  the  whole  complex 
of  indications  for  the  vaginal  coeliotomy  may  be  ful- 
filled. 

Up  to  the  present  time  the  simple  anterior  or  posterior 
incision  has  sufficed  for  this  method,  but  the  uterus  tolerates 
very  well  the  combined  procedure,  i.e.,  opening  of  both  culs- 
de-sac,  and  perhaps  in  the  near  or  remote  future  such  a 
method  will  be  '  discovered  '  again  with  its  '  very  important 
advantages.' 

Following  up  the  vaginal  radical  operation,  we  will  take 
up  the  routine  steps,  and  proceed  now  to  the  haemostasis  and 
excision  of  the  organs. 


SIXTH  STAGE  :  HAEMOSTASIS  AND  EXCISION — THE  NUMBER 
OF  CLAMPS  AND  METHOD  OF  THEIR  APPLICATION. 

The  uterus  and  adnexa  have  now  been  completely  freed 
and  brought  down  into  the  vagina.  A  pedicle  has  been 
formed  right  and  left ;  but  up  to  this  point  nothing  of  im- 
portance has  been  done  for  the  control  of  haemorrhage. 
Either  the  ligature  or  the  clamps  may  now  be  employed,  for 
when  the  organs  have  been  so  exposed,  it  is  as  easy  to  control 
the  haemorrhage  with  ligatures  as  with  forci-pressure. 


94  THE   VAGINAL  RADICAL  OPERATION 

Here,  as  in  every  hysterectomy  performed  with  the  aid  of 
the  clamps,  different  modifications  are  to  be  considered ; 
thus  the  forceps  may  be  applied  from  above  or  from  below  ; 
we  may  use  a  few  only  (one  or  two  on  each  side)  with  long 
blades,  or  a  greater  number  with  short  blades.  As  far  as  a 
general  rule  can  be  given  here,  the  particular  method  to  be 
employed  must  depend  on  the  pathological  condition  of  the 
uterus  and  appendages ;  but  we  may  observe  that  when  it  is 
possible  to  first  free  all  the  parts  and  form  suitable  pedicles, 
not  only  is  each  of  the  methods  of  applying  the  clamps 
possible,  but  all  are  also  opportune.  Where  this  is  not  the 
case,  and  some  of  the  pedicles  must  be  secured  in  advance, 
it  necessarily  follows  that  many  clamps  must  be  used,  and 
that  they  must  be  applied  from  below. 

In  the  first  case,  in  'consecutive'  clamping — i.e.,  forci- 
pressure  applied  after  the  parts  are  completely  freed — the 
direction  of  the  clamps  may  be  discussed  with  about  the 
same  profit  as  that  which  accrues,  for  instance,  from  the 
discussion  of  the  advantages  of  the  ligature.  One  is  there- 
fore not  justified  in  laying  down  such  hard  and  fast  rules  as 
does  Baudron,  when,  as  the  representative  of  the  French 
surgeons,  he  says  :  '  Forci-pressure  is  either  preventive  or 
consecutive ;  in  the  first  the  clamps  are  applied  from  below, 
in  the  second  from  above.'  It  is  really  of  but  slight  im- 
portance in  which  direction  the  '  consecutive  '  clamps  are 
introduced. 

Those  who  operate  standing  will  naturally  apply  them 
from  above,  and  it  must  be  admitted  that  in  this  way  a 
second  haemostatic  principle,  torsion  of  the  vessels,  is  added 
to  that  of  force-pressure ;  for  by  the  depression  of  the  handles 
of  the  forceps  the  clamped  vessels  necessarily  revolve  in  an 
arc  of  nearly  180°. 

Operators  who  work  sitting,  involuntarily  introduce  the 
forceps  from  below,  whereby  the  stumps  are  more  easily  and 
firmly  pulled  down  into  the  vagina,  and  their  extra-peritoneal 
position  better  secured.  Here  the  traction  on  the  pedicles 
forms  the  wound  surface  into  a  funnel,  whose  point  lies,  and 
must  remain,  extra-peritoneal  and  intra-vaginal. 

Just  as  equally  good  results  are  obtained  by  applying  the 


HJBMOSTASIS 


95 


forceps  from  below  or  from  above,  so  also  in  general  their 
number  is  a  matter  of  indifference.  Working  on  an  organ 
which  lies  entirely  free,  it  is  certainly  easy  in  practice  to  put 
on  a  single  large  clamp,  reaching  from  the  infundibulo-pelvic 
ligament  to  the  base  of  the  broad  ligament,  or  vice  versa. 
One  equally  long  but  of  lighter  form  may  with  advantage  be 
put  on  behind  (external  to)  this,  to  ensure .  against  retraction 
of  the  tissue  out  of  its  grasp  (Doyen).  In  applying  these 


FIG.  24. — APPLICATION  OF  CLAMPS  FROM  BELOW. 


is 


in 


instruments  under  full  control  of  sight  and  touch,  it 
difficult  to  see  why  the  intestine  or  ureter  should  be 
special  danger,  as  is  sometimes  stated. 

As  a  matter  of  fact,  we  advocate  the  application  of  several 
clamps  on  each  side,  put  on  from  below,  each  one  higher 
than  the  preceding  one  (Figs.  24,  25).  In  the  first  place,  an 
equal  degree  of  compression  is  thus  made  on  all  parts  of  the 
pedicle,  giving  absolute  security  against  haemorrhage,  while 
the  long  elastic  clamp,  in  spite  of  the  best  workmanship  and 


96  THE   VAGINAL  RADICAL  OPERATION 

finish,  often  shows  more  or  less  weakness,  especially  near 
the  lock.  In  the  second  place,  when  several  clamps  are 
used  the  danger  of  haemorrhage  after  their  removal  is  much 
less  ;  and  when  they  have  been  applied  from  below  it  is 
impossible  for  the  elasticity  still  remaining  in  the  stumps  to 
cause  a  rapid  untwisting  of  the  same,  and  a  loosening  of  the 
thrombi  after  the  clamps  are  taken  off. 

Furthermore,  in  case  of  a  retraction  of  the  pedicle  during 
operation,  which  may  occur  with  the  clamps  as  well  as  with 


FIG.  25. — APPLICATION  OF  CLAMPS  FROM  BELOW.1 

the  ligature  when  several  have  been  employed,  it  is  easy  to  seek 
out  and  expose  the  bleeding-point,  using  the  clamps  already 
in  place  as  retractors,  and  for  making  traction. 

But,  after  all,  we  admit  that  such  discussions  are  more  or 
less  of  a  theoretical  nature,  and  we,  like  others,  have  had 
equally  favourable  results,  whether  we  have  used  a  few  long 

1  The  schematic  Figs.  24,  25,  26,  27,  36,  37,  are  from  drawings  made  by 
Dr.  Vogel. 


H^EMOSTASIS 


97 


forceps  or  several  short  ones,  and  whether  they  have  been 
applied  from  above  or  from  below. 

There  is  still  one  point  in  the  clamp  technique  which 
experience  has  taught  us,  and  which  we  would  emphasize, 
namely,  that  in  using  more  than  one  clamp  for  the  whole 


FIG.  26. — APPLICATION  OF  CLAMPS  FROM  ABOVE  AND  FROM  BELOW — 
FAULTY  METHOD. 

width  of  the  ligament,  their  direction  must  never  be 
changed — that  is,  all  must  be  put  on  from  below,  or  all 
from  above.  Suppose  that  one  has  been  applied  from  above, 
the  other  from  below  (Fig.  26) :  through  the  traction  of  the 
upper  one  as  it  swings  downward  by  its  own  weight,  a 

7 


THE   VAGINAL  RADICAL  OPERATION 


laceration  of  the  highly  vascular  broad  ligament  may  occur 
at  the  point  where  the  forceps  come  in  contact,  leading  to 
profuse  haemorrhage  (Fig.  27). 

Such  an  event  is  possible  when  one  uses,  for  instance, 
Segond's  method,  in  which,  without  exception,  the  blood- 
supply  to  the  cervix  is  secured  previously,  i.e.,  from  below, 
and  then,  after  the  separation  of  the  body  of  the  uterus, 
consecutive  haemostasis  is  applied  from  above.  The  same 
with  the  method  of  Quenu,  who  applies  a  clamp  to  the 


FIG.  27. — EFFECT  OF  APPLICATION  OF  CLAMPS  FROM  ABOVE  AND  FROM 

BELOW. 

uterine  artery  on  each  side,  and  then,  after  freeing  both  halves 
of  the  uterus,  clamps  the  rest  of  the  ligament  from  above. 

To  return  to  the  description  of  the  details  of  the  opera- 
tion. By  means  of  the  fixation  forceps  the  womb  is  drawn 
sharply  forward,  and  to  the  side  opposite  the  one  to  which 
the  clamps  are  to  be  first  applied,  unfolding  very  completely 
in  this  way  the  ligament  and  its  vessels.  It  is  especially 
important  to  expose  the  region  of  the  uterine  arteries  by 
drawing  the  portio  well  to  the  opposite  side. 


H&MOSTASIS  99 


We  begin  generally  with  the  left  adnexa.1  Here,  as 
should  always  be  done  in  applying  the  clamps,  a  ringer  is 
passed  along  the  posterior  surface  of  the  broad  ligament, 
which  is  not  under  visual  control,  forming  a  safe  guide  for 
the  posterior  blade  of  the  forceps.  The  finger  behind  prevents 
(as  the  eye  does  in  front)  any  tearing  or  dissecting  up  of 
the  ligament  by  the  points  of  the  clamp,  and  likewise  guards 
against  the  dangerous  inclusion  of  gut  or  omentum. 

The  operator  passes  the  left  index-finger  through  the  pouch 
of  Douglas,  behind  the  corresponding  ligament,  and  the 
first  clamp  is  pushed  up  beside  it  into  place  (Fig.  28). 

If,  through  attempts  at  coughing  or  vomiting,  intestinal 
loops  or  portions  of  omentum  are  forced  into  the  gap  in 
the  peritoneum,  they  are  easily  held  back  in  this,  as  in  the 
later  stages,  by  the  retractors,  by  mounted  sponges,  or  by  a 
moderate  raising  of  the  pelvis. 

If  the  operator  chooses  to  employ  the  long  clamps,  taking 
in  the  whole  depth  of  the  broad  ligament,  and  securing  all 
its  vessels  at  once,  after  the  large  Doyen's  clamp  (Fig.  10  a) 
is  in  place,  a  lighter  protective  clamp  must  be  applied  to  the 
outer  side  of  it.  Then  with  a  few  snips  of  the  scissors  the 
tissues  are  cut  through  to  the  inner  side  of  the  first  clamp. 
A  knife  answers  as  well,  or,  if  desired,  the  Paquelin's  cautery. 

Naturally,  the  direction  of  the  clamps,  when  applied  from 
below,  is  upward  and  outward. 

If  one  intends  to  use  several  clamps,  the  first  is  applied 
from  below  to  the  tissues  containing  the  uterine  vessels,  and 
then  this  part  is  cut  away  almost  to  the  point  of  the  instru- 
ment, whereby  a  place  is  made  for  the  application  of  the 
next  one  above,  and  to  the  inner  side  of  the  first.  In  this 
fashion  the  whole  ligament  is  included  within  two  or  three, 
or  at  the  most  four  clamps,  which  are  placed  regularly,  one 
at  the  side,  and  above  the  other,  all  having  a  parallel  direc- 
tion (Figs.  24,  25).  From  below  upward  each  clamp  lies  to 
the  inner  side  of  the  preceding  one,  and  the  general  direction 
of  all  is  upwards  and  outwards,  corresponding  to  the  surface 
extent  of  the  ligament  in  the  funnel  of  the  true  pelvis. 

1  Figs.  28  and  29  represent  the  right  adnexa  being  clamped  first  ;  as  a 
rule  we  begin  with  the  left. — L.  and  Th.  L. 

7—2 


100 


THE  VAGINAL  RADICAL  OPERATION 


To  avoid  retraction  of  the  tissue  out  of  the  blades  of  the 
forceps  (without  reference  to  the  better  or  poorer  quality  of 


FIG.  28. — APPLICATION  OF  THE  FIRST  CLAMP  ON  THE  RIGHT  ADNEXA  ;  THE 
LEFT  FOREFINGER  BEHIND  THE  RIGHT  BROAD  LIGAMENT. 

the  instruments),  we  make  it  a  rule  not  to  sever  the  ligament 
too  close  to  the  edge  of  the  clamps,  and  especially  not  to 
shave  it  off  smooth. 


H&MOSTASIS  101 

The  absence  of  bleeding  from  the  uterine  end  of  tfie 
severed  broad  ligament  is  explained  by  the  peculiar  arrange- 
ment of  the  vessels  :  there  are  no  important  anastomoses 
between  the  upper  and  lower  vascular  areas  on  the  same 
side,  just  as  there  are  none  between  the  two  lateral  uterine 
halves. 

Since,  as  we  have  shown  in  a  previous  chapter,  after  the 
bladder  and  ureters  have  been  completely  displaced  upwards, 
the  whole  extent  of  the  broad  ligament  may  be  clamped  off 
without  danger,  it  is  unnecessary  to  keep  to  the  direction 
given  by  Baudron  :  *  The  incisions  should  be  made  as  close 
as  possible  to  the  uterine  tissue.'  On  the  contrary,  espe- 
cially in  the  extirpation  of  a  cancerous  uterus,  one  cannot 
remove  too  much  of  the  adjacent  tissue,  even  when  macro- 
scopically  unaffected. 

In  dealing  with  the  other  side,  the  right,  there  are  two 
methods.  One  may  proceed  in  a  manner  exactly  similar  to 
that  in  which  the  first  ligament  was  divided.  The  uterus, 
more  especially  the  portio,  is  drawn  sharply  forward  and 
toward  the  patient's  left  thigh  by  means  of  the  fixation 
forceps,  and  the  operator's  left  index-finger,  or  two  fingers 
if  desired,  passed  behind  the  right  broad  ligament  as  a  guide 
(Fig.  29).  Then,  as  with  the  other  side,  the  successive 
clamping  and  incising  follow  in  succession,  until  the  last  and 
uppermost  forceps  grasps  the  infundibulo-pelvic  ligament. 

Or,  according  to  a  second  method,  the  severed  left  tube 
and  ovary,  together  with  the  uterus,  are  rotated  outwards, 
i.e.,  toward  the  corresponding  (right)  thigh  of  the  patient, 
about  an  imaginary  vertical  axis  passing  through  the  as  yet 
undisturbed  right  broad  ligament.  That  which  was  originally 
the  posterior  surface  of  the  broad  ligament  now  lies  to  the 
front,  and  is  quite  exposed  to  sight.  The  operator  passes 
one  or  more  fingers  behind  it  as  a  guide,  the  clamps  are  put 
on,  one  large  or  several  shorter  forceps,  as  may  be  desired, 
and  the  ligament  is  cut  away  as  described  for  the  other 
side. 

In  this  way  the  uterus,  with  the  tubes  and  ovaries,  can 
often  be  removed  in  less  time  than  that  required  for  the 
description  ;  regardless  of  the  indication,  whether  for  cancer 


FIG.  29.  —  CLAMPING  OF  THE  OTHER  (HERE  THE  LEFT)  SIDE,  ACCORDING  TO 
THE  FIRST  METHOD.  THE  RIGHT  ADNEXA  CUT  AWAY  FROM  THE  LIGA- 
MENT, WHICH  IS  SECURED  BY  THREE  CLAMPS.  A  FORCEPS  ON  THE  LEFT 

INFUNDIBULO-PELVIC  LIGAMENT  AS  A  'MARKER.' 

of  the  body  or  neck  of  the  uterus,  multiple  myomata,  in- 
flamed or  suppurating  adnexa,  or  actual  tumours  of  the 
latter. 

The  fundamental  condition  necessary  for  this  relatively 


HMMOSTASIS  103 


easy  and  simple  operation  is  merely  the  free  mobility  of  the 
uterus.  Therefore,  when  this  is  only  interfered  with  by  the 
large  size  of  the  cystic  diseased  adnexa,  or  by  intra-  or 
extra-peritoneal  cysts  with  serous,  bloody,  or  purulent  con- 
tents, it  is  easy  to  procure  the  conditions  for  this  form  of 
the  radical  operation :  before  the  extirpation  the  cyst  con- 
tents may  be  evacuated  with  a  trocar,  or,  better  still,  through 
an  incision  which,  if  possible,  should  be  so  placed  as  to  be 
in  the  line  of  the  incision  about  the  portio  which  is  to 
follow ;  or,  after  the  vaginal  incision  is  made,  the  cyst  may 
be  simply  bored  into  with  the  finger.  In  some  cases  the 
cystic  tumour  can  be  exposed  before  being  opened  ;  although 
here  the  first  stages  of  the  hysterectomy  upon  a  more  or  less 
immobile  organ  must  often  be  performed  under  rather  in- 
convenient and  disturbing  conditions,  as,  for  instance,  when 
it  is  necessary  to  work  high  up  in  the  vaginal  vault  in  a 
greatly-narrowed  space,  etc. 

The  evacuation  of  the  serous,  haemorrhagic,  colloid, 
dermoid,  or  purulent  contents  of  cysts  of  the  appendages 
materially  facilitates  the  vaginal  radical  operation,  especially 
for  the  removal  of  the  diseased  appendages  themselves,  in 
those  cases  also  where  the  tumour,  without  itself  in  any  way 
affecting  the  mobility  of  the  uterus,  is,  owing  to  its  size, 
firmly  wedged  in  the  pelvis,  and  is  but  slightly,  if  at  all, 
movable.  Here  its  diminution  can  be  effected  under  visual 
control,  at  any  stage  of  the  operation,  though  most  con- 
veniently after  the  complete  separation  of  the  uterus. 

As  the  contents  of  the  sac  flow  out  at  the  lowest  point, 
the  opening  in  the  vagina,  no  fear  of  peritoneal  infection 
need  be  entertained,  for  the  vagina  forms  a  natural  outlet 
along  which  the  fluids  escape  safely  without  coming  in 
contact  with  the  peritoneum. 

Even  after  the  most  extensive  evacuation  of  this  sort  we 
use  no  irrigation  or  antiseptic  whatever,  because,  according  to 
our  experience,  the  mere  sponging  away  with  sterilized  gauze 
does  away  with  the  danger  of  infection.  In  a  previous  chapter 
it  has  been  shown  how  rapidly  and  safely  the  whole  wound 
surface  heals  extra-peritoneally  with  the  open-wound  treat- 
ment. 


104  THE  VAGINAL  RADICAL  OPERATION 

Finally,  we  must  bear  in  mind  the  results  of  recent  in- 
vestigations concerning  the  inoculability  (by  implantation) 
of  the  epithelial  elements  of  the  so-called  colloid  cystoma  of 
the  ovary  ;l  in  evacuating  such  tumours  in  the  course  of  the 
vaginal  operation  it  is  better  to  avoid  an  incision,  employing 
merely  puncture,  in  order  to  lessen  the  risk  of  inoculation  of 
the  wound  surface. 

There  is  another  curious  phenomenon  to  be  referred  to 
at  this  point.  Sometimes  after  resecting  the  uterus  and 
appendages  there  is  heard  a  peculiar  hissing  sound — stridor 
vaginalis. 

It  occurs  as  the  result  of  air  entering  the  abdominal  cavity 
through  the  vagina,  due  to  the  change  of  respiratory  pressure, 
when,  as  in  some  cases,  there  is  a  valve-like  closure  of  the 
vaginal  vault  by  flaps  of  peritoneum. 

SEVENTH  STAGE:  REVISION  OF  THE  WOUND — INTRODUCTION 
OF  THE  GAUZE — PROCEDURE  IN  CASE  OF  A  TOO  LARGE 
OR  TOO  SMALL  OPENING  IN  THE  VAGINAL  VAULT. 

After  removing  the  uterus  and  adnexa,  the  only  point 
requiring  attention  is  the  absolute  control  of  haemorrhage. 
The  wound  in  the  anterior  vaginal  vault  and  in  the  anterior 
paracervical  tissue  bleeds  but  slightly,  excepting  in  special 
hyperaemias  of  the  genital  area,  pregnancy,  puerperium, 
hyperplasia  of  the  uterus,  operation  during  the  menstrual 
period,  etc.  This  may  be  regarded  as  quite  an  exceptional 
occurrence.  Here,  as  in  the  bleeding  from  the  posterior 
vaginal  wound,  and  the  thick  layer  of  perirectal  connective 
tissue,  a  few  light  haemostatic  forceps  suffice  to  control  the 
oozing.  During  the  application  of  these  instruments,  the 
posterior  vaginal  wall,  which  is  often  rolled  inwards,  can 
easily  be  everted  with  the  light  forceps,  one  part  after  the 
other. 

Up  to  the  moment  in  which  the  internal  genital  organs 
are  resected,  this  haemorrhage  has  no  importance,  for  up  to 
this  time  the  vessels  concerned  have  been  compressed  by  the 
uterus. 

1  J.  Pfannenstiel, '  Carcinombildung  nach  Ovariotomien,'  '  Zeitschrift  f. 
Geburt.  und  Gynak,'  1894,  Bd.  28. 


REVISION  OF  THE  WOUND 


For  isolating  the  edges  of  the  vaginal  wound,  as  well  as 
for  exposing  the  clamped  pedicles,  the  clamps  themselves, 
together  with  the  retractors,  render  good  service.  They  are 
carefully  assorted  and  separated  into  three  groups,  one 
corresponding  to  the  posterior,  the  other  two  to  the  lateral 
walls  of  the  vagina.  On  the  anterior  vaginal  wall,  as  above 
stated,  clamps  are  very  seldom  applied.  The  cavity  thus 
formed  (Fig.  30),  which  may  be  enlarged  inwardly  by  press- 
ing the  points  of  the  forceps  outwards  and  away  from  each 
other,  forms  at  every  point  a  transverse  section  of  a  pyramid, 
which  is  open  at  the  top.  The  long  retractor  is  now  intro- 
duced along  the  anterior  vaginal  wall  (Fig.  30).  The  whole 
wound  surface,  with  the  intestine  and  omentum  in  the  back- 
ground, now  lies  quite  exposed  to  view,  and  ready  for  the 
application  of  any  instrument  or  instruments  that  may  be 
desired. 

Formerly  we  often  united  the  margin  of  the  posterior 
wound  in  the  vagina  to  that  of  the  overlying  peritoneal  edge, 
as  is  generally  done  in  the  usual  ligature  method.  At 
present,  however,  we  do  not  ascribe  any  value  to  this 
particular  form  of  '  embroidery,'  and,  after  opening  the  pouch 
of  Douglas,  do  not  trouble  ourselves  any  further  about  the 
peritoneum. 

Now  comes  the  revision  of  the  pedicles.  In  order  to 
guard  against  a  later  haemorrhage,  the  traction  of  the  clamps 
on  the  pedicles,  whether  from  their  own  weight,  or  effected 
by  the  assistant,  is  now  relaxed.  To  obtain  complete  relaxa- 
tion of  the  pedicles,  it  is,  in  fact,  advisable  to  push  the 
forceps  slightly  inwards.  In  this  way  any  small  vessel  which 
may  have  escaped  the  clamp,  but  is  still  indirectly  com- 
pressed by  torsion  or  traction,  will  show  itself  now,  instead  of 
later,  when  the  patient  is  in  bed.  The  patient,  if  in  the 
Trendelenberg  position,  is  lowered,  and  kept  here  quietly  for 
a  few  moments.  This  pelvic  elevation  itself  may  in  some 
cases,  especially  with  a  weakened  heart,  be  enough  to  check 
haemorrhage  from  the  smaller  vessels. 

Should  one  of  the  pedicles  continue  to  bleed,  it  must  be 
provided  with  a  new  clamp,  or  several  if  necessary.  If  by 
accident  a  clamp  has  slipped  off,  or  a  branch  of  the  uterine 


io6 


THE  VAGINAL  RADICAL  OPERATION 


or  ovarian  artery,  or  a  vein  in  the  broad  ligament,  still  bleeds, 
one  must  not  waste  time  with  a  temporary  gauze  tampon, 
whose  only  effect  is  to  obstruct  the  view  of  the  field ;  far 


FIG.  30.  —  EXPOSURE  AND  SPREADING-OUT  OF  THE  WOUND  BY  THE  CLAMPS 

AND  RETRACTOR. 


less  should  one  trust  entirely  to  such  a  measure.  The 
forceps  already  in  place  are  carefully  separated  from  each 
other,  and  the  bleeding-point  exposed.  Then  the  oozing 


INTRODUCTION  OF  THE  GAUZE  107 

blood  is  quickly  sponged  away,  and  a  fresh  clamp  applied 
under  direct  visual  control. 

This  unimportant  kind  of  haemorrhage  at  the  end  of  the 
operation  is  not  oftener  met  with  in  the  clamp  method  than 
in  the  ligature  method,  and  a  death  from  haemorrhage 
during  or  after  a  vaginal  hysterectomy  with  the  clamps  is 
the  fault  of  the  operator,  not  of  the  method. 

If  one  of  the  ovarian  arteries  is  torn  off  during  the  delivery 
of  the  adnexa — an  accident  which  possibly  occurs  often  with 
those  operators  whose  qualification  for  the  vaginal  radical 
operation  consists  mainly  in  their  possessing  the  clamps — 
the  haemorrhage  from  the  retracted  end  of  the  vessel  can  be 
checked  only  by  a  ventral  laparotomy. 

After  all  the  bleeding  has  ceased,  the  clamps  are  again 
used  as  retractors  in  the  manner  above  described,  and  any 
fluid  or  blood  that  may  have  collected  is  wiped  out  with 
mounted  sponges.  Then  with  an  ordinary  long  dressing 
forceps,  or  clamp,  a  strip  of  sterilized  gauze  is  introduced 
into  the  space  between  the  clamps  (Fig.  31).  The  central 
strip  is  knotted  at  its  outer  end  so  as  to  distinguish  it  from 
the  others.  It  is  passed  well  upwards,  pressing  back  the 
intestinal  coils  and  the  omentum,  and  separating  the  wound 
surface  and  the  points  of  the  clamps  from  the  abdominal 
cavity.  The  strip  is  quite  loose,  and  to  avoid  retention  of 
the  discharge,  or  peritoneal  irritation  (reflex  vomiting),  must 
not  be  packed  in  too  firmly,  since  it  is  primarily  a  drain 
and  not  a  tampon.  Then  the  front  vaginal  wall,  which 
is  generally  somewhat  inverted,  is  smoothed  out  with  a 
retractor,  and  along  with  the  anterior  flap  of  peritoneum 
from  the  vesico-uterine  space  is  lifted  up  while  a  second 
strip  of  gauze  is  introduced,  being  carried  up  to  the  edge  of 
the  vaginal  wound,  between  it  and  the  clamps.  This  strip 
is  of  the  same  length  as  the  first,  but  is  only  double  instead 
of  quadruple.  A  third  and  fourth  are  introduced  between 
the  clamps  and  each  lateral  wall,  and  finally  a  fifth  along 
the  posterior  wall  under  the  forceps.1  In  every  case  the 

1  Lately  we  have  simplified  this  drainage  ;  we  introduce  now,  as  a  rule, 
only  the  central  strip,  dispensing  with  the  other  four.  The  results  are 
identically  the  same. — L.  and  Th.  L. 


io8  THE  VAGINAL  RADICAL  OPERATION 

strips  should  be  counted,  so  that  afterwards  none  be  left 
behind,  when  with  a  wide  vagina  or  an  unusually  large 
opening  in  the  vault  one  or  two  more  than  usual  have  been 
used. 

Even  if  such  an  oversight  is  not  directly  dangerous,  a 
forgotten  piece  of  gauze  may  delay  the  process  of  healing, 
and,  as  a  foreign  body,  increase  the  secretion  in  an  un- 
desirable manner,  until  finally  a  vaginal  irrigation  reveals  the 
source  of  the  trouble. 

Before  each  strip  is  introduced,  the  corresponding  vaginal 
region  is  exposed  by  lifting  the  clamps  and  pressing  in  a 
retractor,  and  then  freed  from  clots  by  sponging  with  a 
gauze  pledget.  Finally,  all  portions  of  the  vaginal  wall  are 
smoothed  out  in  this  way,  and  lifted  up  by  the  strips,  which 
form  a  protecting  mantle  of  gauze  for  the  soft  parts. 

The  anterior  vaginal  wall,  after  being  raised  into  place, 
forms  more  particularly  a  protecting  membrane  for  the 
denuded  base  of  the  bladder,  while  the  gauze  lying  along  the 
posterior  wall  forms  a  bed  for  the  clamps  (which  by  their 
weight  tend  to  fall  back  towards  the  perineum),  and  prevents 
the  corresponding  tipping  upwards  of  their  points. 

We  have  found  this  form  of  dressing,  or,  better  expressed, 
packing  and  care  of  the  wound,  satisfactory  in  every  respect. 
With  such  drainage  there  is  nowhere  a  dead  space,  or 
reservoir  for  stagnating  secretions ;  all  the  fluids  must  flow 
outward  along  the  natural  oblique  pelvic  outlet.  Further, 
any  haemorrhage  that  may  occur  is  recognised  at  once  by 
the  escape  of  blood  externally,  since  the  previous  separation 
of  the  vaginal  walls  prevents  the  occurrence  of  a  haematocele, 
and  makes  it  impossible  for  a  fatal  internal  haemorrhage  to 
remain  concealed. 

The  number  of  clamps  left  in  place  in  such  practically 
simple  cases  as  we  are  now  describing  varies  from  four  to 
ten. 

The  procedure  as  described  for  this  stage  of  the  operation 
is  liable  to  some  modification  when  the  extirpation  of  the 
uterus  and  appendages  is  begun  with  a  longitudinal  (anterior 
colpotomy)  instead  of  the  oval  incision.  Here,  after  check- 
ing the  haemorrhage  from  the  stumps,  the  paracervical 


A  FTER-TREA  TMENT 


bladder  wound  should  be  sutured  at  once,  through  the  vagina, 
or  by  means  of  supra-pubic  section,  according  to  the  situa- 
tion of  the  injury. 

Occasionally  with  a  rigid  vagina  and  a  too  vigorous 
pressure  on  the  perineal  retractor,  small  perineal  tears  may 
be  produced,  which  are  best  united  at  once  with  one  or  two 
stitches. 

Special  care  should  be  taken  in  carrying  the  patient  from 

*  operation  table  to  the  bed.     While  this  is  being  done,  an 

lant  should  support  the  clamps  with  his  hand.     In  bed 

ient  is  laid  flat,  with  the  legs  slightly  abducted. 

bunch  of  clamps  is  wrapped  in  a  sterilized  napkin  to 

the  thighs  from  contact  with  the  metal,   and  the 

lass  supported  on  a  small  cushion  of  cotton-wool  or 

i  gauze.     By  the  adoption  of  this  little  precaution, 

e  never  had  a  pressure  necrosis  of  the  vulva  or  vagina, 

described  by  Lafourcade. 

square  pad  of  wood-wool,   anointed  with  vaseline,  is 
ed  under  the  nates  to  protect  the  skin  from  wetting  and 
oriation  by  the  oozing  wound  secretion, 
t^or  many  patients  it  is  useful,  as  well  as  a  great  relief,  to 
pport  the  knees  from  the  first  by  a  pillow,  so  that  the 
nighs  are  abducted  and  flexed  without  any  muscular  effort, 
avoiding  in  this  way  the  rigidity  of  the  abdominal  muscles. 
The  head,  trunk,  and  pelvis  are  on  a  level  with  each  other ; 
the  latter  is  not  elevated,  because  we  wish  to  be  sure  of  the 
free  escape  of  the  wound  secretions. 

We  discard  catheterization,  and  introduce  a  permanent 
soft  catheter  after  the  operation  only  under  special  con- 
ditions which  render  the  first  procedure  difficult  for  the 
nurse  and  painful  to  the  patient.  Such  are  cases  in  which 
the  urethral  orifice  naturally  lies  close  to  the  front  vaginal 
wall,  or  where  it  is  strongly  pulled  down  by  the  clamps,  or, 
finally,  where  there  is  such  a  mass  of  instruments  that  the 
orifice  is  hidden  from  view  and  is  inaccessible.  For  this 
purpose  the  Pezzer  soft-rubber  catheter  has  answered  very 
well. 

The  catheter  drains  into  a  flat  vessel  at  the  side  of  the 
clamp  handles,  and  is  removed  at  the  same  time  as  these 


ii2  THE  VAGINAL  RADICAL  OPERATION 

instruments,  usually  within  twenty-four  or  forty-eight  hours. 
During  this  two  days'  retention  we  have  never  observed  the 
formation  of  incrustations  of  urinary  salts  or  any  other 
obstruction  within  its  calibre,  and  we  therefore  see  no  dis- 
advantage in  its  employment  in  this  way. 


CHAPTER  IV. 

REMOVAL  OF  THE  ADNEXA  AND  ADHERENT  UTERUS  WITH- 
OUT MORCELLATION. 

THIS  method  applies  to  the  extirpation  of  the  uterus  in  situ, 
when  its  descent  is  hindered  by  peri-  or  para-metric  infiltra- 
tion, or  disease  of  one  or  both  appendages.  It  is  not,  how- 
ever, the  method  of  election  for  all  cases  that  come  under 
this  category,  but  comes  into  use  only  when  the  circumstances 
of  the  case  forbid  the  adoption  of  a  technically  easier  pro- 
cedure— in  other  words,  when  we  are  prevented  from  using 
the  means  by  which,  in  the  vaginal  radical  operation,  every 
form  of  fixation  may  be  overcome,  i.e.,  morcellement. 

Therefore  the  sole  indication  for  this  procedure  is  the  immobile 
carcinomatous  or  sarcomatous  uterus  in  which  every  mutilating 
operation  must  be  avoided  on  account  of  the  danger  of 
cancerous  inoculation.  A  cancerous  womb  which  is  mobile 
should  be  removed  by  the  method  previously  described, 
which  is  incomparably  easier ;  so  also  such  an  organ  when 
merely  indirectly  fixed  by  cystic  disease  of  the  appendages 
(pyo-  or  hydro-salpinx  or  cyst  of  the  ovary)  should  be  freed 
by  puncture,  incision  or  perforation  of  the  sac  from  the 
vaginal  incision,  and  then  treated  as  a  mobile  organ. 

Where,  on  the  contrary,  the  adherent  unilateral  or  bilateral 
cystic  tumours  are  too  unfavourably  situated  for  preliminary 
evacuation  through  the  vagina,  or  where  direct  fixation  of 
the  uterus  exists,  either  alone  or  in  addition  to  these  cysts, 
the  only  course  is  to  extirpate  the  uterus  in  situ,  regardless 
of  its  fixation. 

The  method  is  equally  applicable  in  dealing  with  carcinoma 
or  sarcoma  of  the  uterine  neck  and  of  the  uterine  body. 


REMOVAL  OF  ADNEXA  AND  ADHERENT  UTERUS     113 

Since  morcellement  must  be  wholly  avoided  in  malignant 
new  growths,  it  follows  that  the  vaginal  extirpation  in  these 
cases  is  only  possible  in  dealing  with  organs  of  a  certain 
size,  i.e.,  such  organs  must  be  capable  of  passing  through 
the  vagina  without  any  artificial  reduction  of  their  bulk. 

When  a  radical  operation  still  seems  possible  with  a  uterus 
too  greatly  enlarged  by  tumour  formation  to  pass  the  vaginal 
outlet,  one's  choice  is  limited  to  abdominal  hysterectomy. 
Whether  the  enlargement  depends  on  the  corpus  carcinoma 
itself,  or  upon  complicating  myomata,  the  cancer  is  guarded 
by  healthy  myometrium  and  perimetrium  forming  a  sort  of 
capsule,  so  that  there  is  no  danger  of  its  dissemination 
during  removal,  even  in  an  abdominal  extirpation. 

If,  however,  the  space  necessary  for  the  vaginal  delivery 
of  this  sort  of  tumour  unmutilated  can  be  gained  by  a 
vagino-perineal  section,  we  should  prefer  this  to  ventral 
laparotomy  on  account  of  its  advantages,  previously  discussed. 
In  passing,  we  may  state  that  such  are  the  only  occasions  in 
connection  with  the  vaginal  radical  operation  when  we  are 
not  able  to  dispense  with  perineal  section. 

The  same  indications  hold  good  either  for  the  abdominal 
or  the  vaginal  extirpation  in  dealing  with  cancer  of  the 
uterine  neck,  complicated  by  fibromata  of  the  body,  likewise 
in  cancer  of  the  cervix  or  body  affecting  a  normal  or  slightly 
enlarged  uterus,  when  at  the  same  time  a  narrow  or  stenosed 
vagina  exists.  For  in  cervical  cancer,  even  when  small  and 
quite  localized,  neither  the  body  of  the  uterus  nor  even  the 
fundus  must  be  mutilated,  for,  as  the  most  recent  researches 
show,  the  cancer  cells  may  have  been  carried  in  the  lymph  or 
blood-stream  as  far  as  the  fundus.  Compared  with  abdominal 
laparotomy,  the  vagino-perineal  incision  is  here  the  lesser  of 
the  two  evils,  hence  the  former  remains  as  the  method  of 
necessity  for  large  carcinomatous  uteri  only. 

Another  question  is  whether  abdominal  extirpation  is 
specially  indicated  when  the  carcinoma  has  attacked  the 
parametrium,  the  uterus  not  having  undergone  any  material 
enlargement. 

Besides  our  practical  experience,  the  following  theoretical 
considerations  speak  strongly  in  favour  of  the  vaginal 

8 


ii4  THE   VAGINAL  RADICAL  OPERATION 

route :  Firstly,  there  can  be  no  doubt  that  the  ligamentous 
tissue  can  be  as  widely  extirpated  by  the  aid  of  the  clamps  as 
it  can  be  from  the  ventral  incision,  namely,  right  up  to  the 
lateral  wall  of  the  pelvis ;  secondly,  there  is  a  greater 
possibility  of  inoculation  during  the  abdominal  operation, 
especially  on  account  of  the  danger  of  the  dissemination  of 
cancer  cells  by  the  needles  and  ligatures  which  are  passed 
through  the  ligaments.  Finally,  the  general  advantages  of 
the  vaginal  over  the  abdominal  route  are  decidedly  in  favour 
of  the  former. 

The  chief  difference  between  the  operation  described  in 
the  preceding  chapter,  the  extirpation  of  the  mobile  uterus, 
and  this  method  of  removing  the  adherent  organ  without 
morcellation,  lies  in  the  necessity  of  primary  clamping  in  the 
latter  operation.  Here  the  preliminary  isolation  of  the 
organ  is  out  of  the  question.  The  clamps  now  take  the 
place  of  the  ligature  purely  upon  practical  grounds,  since 
they  have  the  great  advantage  that  by  their  use  even  the 
gravest  fixation  of  the  womb  is  not  an  insurmountable 
obstacle  to  extirpation.  Naturally,  one  has  to  work  at  both 
sides  of  the  uterus,  with  many  short  clamps,  corresponding 
to  the  ligatures. 

In  a  certain  number  of  cases  the  immobility  quickly 
diminishes  after  the  first  stages  of  the  extirpation,  either 
because  the  fixation  is  wholly  or  chiefly  limited  to  the  lower 
uterine  segment,  or  because  after  opening  the  peritoneum 
the  finger  can  be  introduced  and  adhesions  and  cicatrices 
broken  up  ;  or,  finally,  because  adherent  cysts  high  up  in 
the  pelvis  can  then  be  broken  up  or  incised,  their  contents 
evacuated,  and  the  uterus  thus  liberated.  The  walls  of  such 
cysts,  when  opened,  are  to  be  seized  and  controlled  with 
forceps,  just  as  is  done  with  the  Nelaton  forceps  in  an 
ordinary  ovariotomy. 

When  under  such  circumstances  a  certain  mobility  of  the 
uterus  is  obtained  in  the  course  of  the  operation,  one  should 
always  try  again  to  first  effect  the  separation  and  pedicle- 
formation,  and  to  secure  the  vessels  secondarily. 

The  details  of  the  procedure  are  as  follows :  All  brittle, 
disorganized  carcinoma  masses  are  to  be  first  cleared  away 


REMOVAL  OF  ADNEXA  AND  ADHERENT  UTERUS     115 

from  the  field  of  operation,  avoiding  meanwhile  all  rough 
manipulation  which  might  injure  the  healthy  structures.  In 
cancer  of  the  body  of  the  uterus,  the  cervix  is  to  be  closed  by 
fixing  the  lips  of  the  portio  together  with  a  strong  volsella. 
When  the  vagino-perineal  section  is  to  be  made,  the  fresh 
wound  should  be  covered  with  sterilized  gauze,  and  this  held 
in  place  by  a  retractor  during  the  whole  operation.  The 
precept  to  keep  all  the  instruments — retractors,  fixation 
forceps  and  clamps — as  much  as  possible  in  the  same  place, 
avoiding  unnecessary  movements,  applies  to  all  hysterec- 
tomies for  malignant  tumours,  not  merely  under  the  above 
circumstances,  but  also  without  the  perineal  section. 

After  the  fixation  forceps  have  been  securely  applied,  for 
which  one  must  depend  mainly  on  the  posterior  lip  of  the 
portio,  or  the  posterior  uterine  wall,  an  incision  is  to  be 
made  round  the  cervix,  the  form  and  course  of  which  will 
depend  entirely  on  the  seat  and  diffusion  of  the  cancer. 
Then  follows  the  denuding  of  the  cervix,  which  is  infinitely 
more  tedious  and  difficult  than  in  the  cases  first  described. 
Often  enough  the  uterine  neck  is  walled  in  on  all  sides  by 
firm  and  tense  inflammatory  products  which  fix  the  uterus 
in  front  as  pericystitis,  laterally  as  parametritis,  on  the 
fundus  and  posterior  surface  as  perimetritis,  periproctitis, 
or  by  cicatricial  masses  which  obliterate  the  entire  pouch  of 
Douglas.  Through  the  formation  of  intra-  or  extra-peritoneal 
indurations  there  is  often  nothing  of  the  pouch  of  Douglas 
remaining  ;  it  is  destroyed.  Blunt  dissection  with  finger  or 
raspatory  does  not  suffice  in  such  cases ;  the  short  firm 
bands  of  scar  tissue  must  be  divided  throughout  with  the 
scissors. 

These  inflammatory  changes  are  the  cause  of  the  very 
considerable  difficulties  often  encountered  in  liberating  the 
bladder  and  ureters,  and  they  make  it  impossible  to  get 
through  the  posterior  cul-de-sac  with  the  first  incision. 

Here,  as  in  all  grave  inflammatory  processes  in  the  pelvic 
connective  tissue,  particular  caution  is  required  to  prevent 
lacerating  the  bladder  or  intestine.  Cicatricial  bands  about 
the  rectum  and  the  lower  portion  of  the  sigmoid  flexure  may 
cause  bulgings  of  their  walls  into  the  perirectal  tissue,  which 

8—2 


ii6  THE  VAGINAL  RADICAL  OPERATION 

from  their  analogy  to  similar  processes  occurring  in  the 
ossophagus  must  be  regarded  as  traction  diverticula,  and 
which  may  be  very  easily  penetrated  through  hasty  attempts 
at  isolation  of  the  genital  organs. 

The  pelvic  as  well  as  the  vesical  portions  of  the  ureters 
may  become  adherent  to  the  uterus  in  consequence  of  in- 
flammatory processes  due  to  the  tumour,  or  independent  of 
it.  The  ureters  may  be  fixed  in  hard  cicatrices,  or  they  may 
be  displaced  by  the  subsequent  retraction  of  this  scar  tissue. 
In  the  same  way  their  normal  course  and  position  may  be 
disturbed  by  the  malignant  tumour  itself  when  its  outgrowths 
project  into  or  towards  the  broad  ligament,  or  by  fibroids 
which  complicate  the  uterine  sarcoma  or  carcinoma. 

From  this  it  follows  that  the  directions  given  for  liberating 
the  ureters  lying  in  normal  tissue  must  frequently  be  more 
or  less  departed  from,  when  conditions  similar  to  the  above 
are  encountered  in  the  pelvis. 

It  is  certain  that  the  occasional  injuries  of  the  ureters  in 
operations  for  carcinoma  uteri  are  to  be  referred  to  such 
displacement  of  these  organs,  and  not  merely  to  the 
cancerous  erosion.  In  the  very  effort  to  radically  free  the 
patient  from  her  malignant  trouble,  the  necessary  considera- 
tion of  these  changes  of  position  is  only  too  easily  over- 
looked. 

When  the  vesico-uterine  fold  has  been  reached,  it  is  to  be 
opened  with  the  scissors  points,  and  a  long  retractor  intro- 
duced ;  or  when  this  is  prevented  by  adhesions  in  the 
anterior  cul-de-sac,  the  necessary  space  is  to  be  obtained  by 
tearing  the  adhesions  away  with  the  finger,  reaching  in  this 
way  the  free  abdominal  cavity  in  front. 

Then,  after  the  bladder  and  ureters  have  been  raised  up, 
the  uterus  and  its  ligaments  become  more  accessible.  Still, 
this  organ  is  not  yet  loosened  from  its  bed  ;  it  cannot  yet  be 
brought  forward  to  the  symphysis  ;  in  fact,  it  can  be  but 
little  moved  out  of  its  position.  Nothing  could  be  more 
dangerous  and  ill-timed  than  to  now  attempt  to  forcibly 
prolapse  it  by  pressure  on  the  abdominal  parietes  above,  or 
by  strong  traction  with  the  fixation  forceps  from  below. 
The  ligaments,  which  are  sodden  and  brittle  from  the 


REMOVAL  OF  ADNEXA  AND  ADHERENT  UTERUS     117 

inflammatory  changes,  even  in  the  absence  of  malignant 
infiltration,  might  easily  be  torn  through,  and,  by  retracting, 
give  rise  to  extremely  dangerous  haemorrhage.  Pus  collec- 
tions about  the  uterus  may  be  only  too  easily  ruptured,  and 
while  the  organ  remains  in  place,  their  contents  may  flow 
into  the  abdomen,  instead  of  being  safely  discharged  through 
the  vagina,  as  is  the  aim  of  the  operation,  and  as  happens 
when  it  is  properly  carried  out.  Finally,  when  the  fundus 
or  adnexa  are  firmly  adherent  to  the  gut,  violent  manipula- 
tion may  lead  to  a  rupture  of  the  intestinal  wall,  which 
naturally  could  not  be  controlled  at  this  stage. 

In  certain  cases  it  is  impossible,  in  the  first  stage  of  the 
operation,  to  raise  the  bladder  and  ureters  sufficiently  to  open 
the  vesico-uterine  fold  without  danger  to  the  urinary  organs. 
Here  only  a  small  portion  of  the  cervix  is  at  first  isolated 
without  opening  the  abdomen  in  front  or  behind  it.  One 
must  for  the  time  being  dispense  with  further  attempts  at 
mobilization,  and  first  secure  the  vessels  entering  the 
denuded  cervix — that  is,  resort  to  primary  clamping. 

The  operator  pushes  one  or  two  fingers  behind  the  portion 
of  the  ligament  containing  the  uterine  vessels,  or,  in  case  the 
pouch  of  Douglas  has  been  opened,  through  this  cul-de-sac. 
Under  this  guidance  a  short  stout  forceps  is  clamped  on  the 
sound  tissue  at  each  side,  and  the  corresponding  portion  of 
the  ligament  cut  through  (Fig.  32).  Sometimes,  when  both 
culs-de-sac  are  obliterated,  this  cut  opens  the  abdominal 
cavity  at  the  side  and  behind. 

In  many  cases,  as  stated,  the  freeing  of  the  cervix  alone  is 
sufficient  to  make  the  remainder  of  the  organ  mobile  ;  in 
others,  the  finger  can  be  pushed  through  the  cul-de-sac  in 
front  or  behind  into  the  peritoneal  cavity,  and  adhesions 
broken  down  which  previously  fixed  the  body,  either  directly, 
or  indirectly  through  the  diseased  adnexa.  Finally,  in 
another  set  of  cases  it  now  becomes  possible  to  accomplish 
this  by  evacuating,  under  visual  control,  cysts  and  abscesses 
lying  high  in  the  pelvis. 

The  uterus  and  appendages,  which  in  the  presence  of 
cancer  are  always  removed  entire,  are  then  freed  by  the 
method  previously  described,  pedicles  formed  and  dealt  with 


ii«  THE  VAGINAL  RADICAL  OPERATION 

secondarily  ;  the  uterine  vessels  alone  are  primarily  clamped. 
If  the  posterior  cul-de-sac  is  still  unopened,  a  closed  forceps 
should  be  forced  through  from  above,  the  ringer  and  retractor 
meanwhile  guarding  the  intestines  (Fig.  22),  or  it  may  be 
cut  through  from  one  side  with  the  scissors  under  visual 
control. 

There  remains  yet  to  be  described  the  method  of  extirpa- 


• 
FIG.  32. — PREVENTIVE  CLAMPING  OF  THE  LEFT  UTERINE  VESSELS. 

tion  in  those  cases  in  which,  even  after  primary  clamping 
and  isolation  of  the  cervix,  it  is  still  impossible  to  set  free  the 
body  of  the  uterus.  This  is  the  pure  form  of  the  method  to 
which  this  chapter  is  devoted. 

The  procedure  is  exactly  similar  to  the  ligature  method  ; 
that  is,  one  clamp  is  applied  after  the  other,  each  one  higher 
than  the  preceding,  and  the  tissue  as  it  is  clamped  is  cut 
through  step  by  step. 


REMOVAL  OF  ADNEXA  AND  ADHERENT  UTERUS     119 

When  the  fixation  is  chiefly  or  wholly  unilateral,  after 
clamping  the  uterine  arteries,  it  is  better  to  liberate  the  less 
affected  side  first,  successively  clamping  and  resecting  the 
ligament  from  below  upwards,  until  this  side  of  the  uterus, 
with  its  tube  and  ovary,  is  free.  After  this  the  uterus,  still 
fixed  on  one  side,  can  be  partially  drawn  down  into  the 
vagina,  together  with  the  portions  already  freed,  and  there 
is  now  room  to  work  along  the  posterior  surface  of  fundus 
and  tube.  Perimetritic  bands,  tubal  adhesions  and  con- 
nections with  the  gut,  if  present,  can  be  reached  and  divided, 
so  that  the  field  of  operation  is  now  sufficiently  exposed  to 
allow  of  the  shelling  out  of  adnexal  tumours  of  the  more 
affected  side.  If  the  posterior  cul-de-sac  is  still  intact,  the 
thickened  peritoneum  is  to  be  cut  through  at  this  point  from 
the  right  or  left. 

Occasionally  in  these  cases  primary  clamping  of  one  side 
of  the  cervix  suffices.  The  uterine  neck  then  becomes  free 
enough  for  the  uterus  and  appendages  to  be  wholly  liberated 
through  the  posterior  cul-de-sac,  and  the  simpler  method  of 
enucleation  can  now  be  employed  without  further  recourse 
to  prophylactic  hsemostasis. 

If,  on  the  contrary,  the  fixation  is  of  equal  extent  on  both 
sides,  or  if  it  consists  mainly  of  dense  perimetritic  encapsu- 
lation, the  clamps  must  be  symmetrically  put  on,  one  after 
the  other,  on  both  sides,  and  the  corresponding  depth  of  the 
ligament  divided  each  time.  In  this  way  the  uterus  can 
be  gradually  drawn  further  down,  the  direction  of  its  long 
axis  remaining  unchanged,  until  finally  the  lateral  cornua  are 
reached.  If  the  adnexa  can  now  be  delivered,  they  are  to  be 
brought  out,  their  pedicles  secured  and  clamped  at  each 
side,  and  then  resected  along  with  the  uterus. 

It  is,  however,  of  no  consequence  in  this  method  if  the 
womb  be  first  extirpated,  either  alone  or  with  the  adnexa  of 
one  side  only,  the  remaining  portions  of  the  diseased  appen- 
dages being  afterwards  removed  by  themselves.  They  are 
seized  at  the  tubal  isthmus  with  the  finger,  or,  better,  with 
an  ovum  forceps,  freed  from  adhesions  as  far  as  possible, 
and  another  forceps  applied  to  the  side  of  the  first.  This 
process  is  repeated  until  the  ovary  and  the  rounded  pavilion, 


120  THE  VAGINAL  RADICAL  OPERATION 

often  intimately  bound  together,  are  brought  out  into  the 
vaginal  canal,  and  the  pedicle  secured. 

It  is  very  useful,  in  dealing  with  all  inflammatory  processes 
of  the  appendages,  to  apply  a  short  clamp  to  the  infundibulo- 
pelvic  ligament  beyond  the  pavilion  as  soon  as  the  tube 
and  ovary  have  been  brought  into  the  vagina.  This  marks 
the  direction  and  the  terminal  point  of  the  row  of  clamps  on 
the  corresponding  side  (Fig.  29),  and  prevents  the  retraction 
of  the  ovary  or  the  end  of  the  tube,  which  was  previously 
firmly  adherent  to  the  lateral  pelvic  wall. 

Another  general  rule  in  liberating  the  adnexa  is  to  be 
mentioned  here,  namely,  that  this  procedure  on  the  left  side 
must  always  be  executed  with  particular  caution,  and  all 
violence  must  be  avoided.  In  the  diffuse  form  of  pelvic 
peritonitis  there  is  often  a  very  intimate  fusion  of  the  sig- 
moid  flexure  with  the  internal  genital  organs  ;  the  frequency 
of  this  condition  has  not  been  sufficiently  recognised. 
Evidently  the  extension,  by  continuity,  of  the  inflammatory 
process  from  the  broad  ligament  to  the  peri-  and  para- 
sigmoidal  tissues  depends  on  their  close  anatomical  relations, 
or,  rather,  on  the  direct  transition  of  the  mesentery  of  the 
flexure  into  the  '  mesentery '  of  the  tube  and  ovary.  The 
contraction  occurring  in  the  inflammatory  products  must 
finally  lead  to  a  direct  fusion  of  the  organs.  Tube  and  ovary 
are  drawn  into  the  convolutions  of  the  flexure,  and  become 
intimately  adherent  to  the  wall  of  the  gut. 

The  definite  and  complete  haemostasis  which  immediately 
follows  the  resection  of  the  womb  and  appendages  is  here, 
as  in  all  cases  of  pelvi-peritonitic  adhesions,  not  so  easy  and 
simple  as  in  the  class  of  operations  first  described.  Besides 
the  marked  hyperaemia  of  the  chronic  inflamed  pericervical 
and  perivaginal  tissues,  the  adhesions  themselves  are,  as  a 
rule,  extremely  vascular.  The  bleeding  shreds  attached  to 
gut  and  omentum  must  often  be  firmly  compressed  for  some 
time  with  mounted  sponges  before  the  oozing  can  be  checked. 
Thick  and  firm  bands  of  adhesion,  especially  when  con- 
nected with  the  omentum,  after  being  brought  into  the 
vaginal  opening,  can  be  most  conveniently  secured  by 
ligatures  before  being  cut  away  with  knife  or  scissors.  For 


TOTAL  EXTIRPATION  WITH  MORCELLEMENT        121 

the  rest,  one  separates  the  adhesions  with  the  finger,  tearing 
them  through,  and  sometimes  having  to  use  considerable 
force.  Sometimes  during  this  process  such  a  profuse  bleed- 
ing starts  that  the  field  of  operation  is  hidden  in  a  few 
seconds.  Mounted  sponges  pressed  down  quickly  one  after 
the  other  soon  clear  away  the  blood  and  expose  the  bleed- 
ing-point. 

Very  occasionally  a  trifling  parenchymatous  haemorrhage 
from  the  lacerated  adhesions  persists  in  spite  of  compression 
and  waiting ;  the  gauze  strip  lying  nearest  the  bleeding-point 
should  then  be  more  firmly  packed  in,  and  one  or  two  extra 
ones  added.  The  Mikulicz  tampon  might  also  be  employed 
here  with  advantage. 

Under  such  circumstances  we  delay  the  return  of  the 
patient  to  bed  in  order  to  be  sure  while  she  is  still  on  the 
table  that  the  bleeding  is  completely  checked. 


CHAPTER  V. 

REMOVAL  OF  THE  UTERUS  AND  APPENDAGES  WITH  THE 
AID  OF  MORCELLEMENT  —  SPLITTING  THE  UTERUS — 
MEDIAN  SECTION  OF  ONE  WALL. 

FOR  the  vaginal  extirpation  of  the  internal  genital  organs, 
the  large  group  of  morcellating  procedures  come  into  opera- 
tion when  the  womb  is  directly  or  indirectly  fixed,  but  free 
from  malignant  new  growths.  In  every  case  the  chief  object 
is  to  first  bring  the  organs  down  into  the  vagina,  their 
separation  thus  preceding  the  control  of  haemorrhage.  All 
the  mutilative  procedures  are  intended  solely  for  this 
purpose,  and  hence  are  not  methods  for  indiscriminate  use. 
One  dissects  or  divides  up  the  uterus  only  until  it  is  possible 
to  deliver  the  remainder  in  one  mass. 

It  is  difficult  to  understand  why  the  technique  should  be 
burdened  with  an  auxiliary  operation  in  cases  where  the 
organs  can  be  extirpated  entire  according  to  the  method  first 
described.  In  the  same  way,  it  must  be  considered  a  funda- 
mental principle  always  to  use  the  simplest  form  of  mor- 
cellement  that  will  suffice  for  the  individual  case. 


122  THE  VAGINAL  RADICAL  OPERATION 

The  simplest  of  the  mutilating  operations  consists  in  the 
splitting  of  one  uterine  wall,  preferably  the  anterior 
(hemisectio  uteri  mediana).  The  mechanical  effect  of  this 
procedure  has  already  been  explained  in  detail  in  the  section 
devoted  to  the  general  technique  (see  p.  47).  After  this 
longitudinal  section,  the  uterus  can  be  unrolled  and  flattened 
out  in  a  way  similar  to  that  in  which  the  organ  is  spread 
open  according  to  Virchow's  post-mortem  technique.  In  this 
way  a  uterus  which  is  too  large  for  flexion  and  delivery 
through  the  vagina  is  in  the  first  place  flattened  and  rendered 
able  to  pass,  and  secondly  the  organ  is  set  free,  and  room  is 
afforded  for  the  finger  to  be  introduced  over  the  fundus  into 
the  abdominal  cavity  to  reach  perimetritic  adhesions  or  the 
adherent  adnexa. 

Whilst  the  most  extensive  of  the  mutilating  operations — 
morcellement  in  the  original  sense  of  the  word — is  for  some 
cases  indispensable,  i.e.,  the  method  of  necessity,  other 
procedures  always  come  into  competition  with  section  of  the 
uterus,  and  sometimes  with  morcellement  itself,  as  methods 
of  election  ;  such  are  operations  of  the  type  of  the  old  Czerny 
procedure  in  hysterectomy  ;  but  they  are  themselves  mutila- 
ting operations.  We  refer  to  hysterectomy  with  the  aid  of 
vagino-perineal  section,  perineal  incision,  sacral  and  para- 
sacral  incision,  sacral  resection,  or  finally  ventral  laparotomy. 
When  these  different  methods  are  employed,  the  diseased 
organs  are  indeed  removed  intact,  but  the  healthy  structures 
remaining  behind  are  injured,  with  the  frequent  result  either 
of  danger  during  the  operation  (haemorrhage)  or  of  later 
functional  disturbances  (paralysis). 

For  this  reason  the  adoption  of  such  measures  seems 
inconsistent,  and  we  therefore  choose  the  harmless  but  not 
less  effective  method  of  dividing  up  the  uterus  itself.  Malig- 
nant tumours  of  the  uterus  are  alone  excluded  from  this 
category ;  ventral  laparotomy  or  perineal  incision  must  be 
here  employed. 

The  indications  for  the  operation  under  discussion,  the 
simplest  of  the  incising  methods,  are :  hyperplastic  or  fibro- 
matous  uteri  up  to  the  size  of  a  man's  fist,  uteri  fixed  by 
parametritic  or  adnexal  disease,  or  a  combination  of  hyper- 


MEDIAN  SECTION  OF  ONE   WALL  OF  THE  UTERUS     123 

trophy  and  fixation.  A  condition  which  is  absolutely 
necessary  for  the  successful  employment  of  this  procedure  is 
that  the  uterine  tissue  be  not  too  soft  or  friable,  as,  for 
instance,  in  the  puerperal  state,  for  then  the  volsellse  simply 
tear  through  the  parenchyma,  and  do  not  fix  or  hold  it 
at  all. 

In  opening  the  uterus,  the  anterior  wall  is  the  one  chiefly 
concerned.  Doyen  proposes  this  as  a  general  method  for 
all  hysterectomies.  It  was  he  who  developed  the  method  in 
its  details  as  a  universal  procedure,  and  described  it  later 
at  the  Brussels  Gynaecological  Congress.  Section  of  the 
posterior  wall  alone  is  but  rarely  employed  ;  sometimes  it 
may  be  useful  for  a  retroflexed,  hyperplastic  uterus  when  the 
anterior  wall  is  strongly  pressed  up  against  the  symphysis. 

One  proceeds  as  follows  :  The  portio  is  seized  by  two 
volsellae,  one  at  each  commissure,  and  in  case  the  womb  is 
firmly  fixed  a  third  may  also  be  applied  on  the  middle  of  the 
posterior  lip  (Fig.  33).  These  forceps  are  allowed  to  remain 
as  landmarks  during  the  whole  operation. 

An  oval  incision  is  made  round  the  portio,  stripping  off 
the  perivesical  and  perirectal  tissues  from  the  cervix.  The 
pouch  of  Douglas  is  opened,  if  possible,  and  cysts  or 
abscesses,  if  present,  are  evacuated  at  the  same  time. 

Since  the  later  manipulation  concerns  only  the  front  wall 
of  the  uterus,  the  forceps  on  the  portio  are  drawn  strongly 
downwards  and  backwards,  and  the  perineal  retractor  is 
removed.  If  there  be  any  difficulty  in  stripping  away  the 
paracervical  tissue  in  front,  one  must  neither  forcibly  raise 
the  bladder  and  ureters,  nor  make  too  violent  traction  on 
the  portio.  It  is  better  to  liberate  at  first  only  one  or  two 
centimetres  of  the  cervix  from  its  connective-tissue  bed,  and 
then  introduce  one  point  of  the  scissors  into  the  cervical 
canal,  and  split  the  cervix  in  the  anterior  median  line  just  to 
where  it  has  been  freed.  A  retractor  held  by  an  assistant 
obliquely  against  the  uterus  marks  the  border-line  and 
protects  the  bladder  at  the  same  time.  It  is  not  necessary 
to  use  a  grooved  director  as  a  guide  for  the  scissors.  A 
fresh  volsella  is  at  once  placed  on  each  lip  of  the  longitudinal 
wound,  rotated  outwards,  and  then  held  by  the  assistant  at 


124  THE  VAGINAL  RADICAL  OPERATION 

each  side  with  moderate  traction.  Then  the  precervical 
tissue  is  still  further  dissected  off,  and  the  bladder  and 
ureters  correspondingly  raised  out  of  the  field  of  operation. 
In  dissecting  upwards  it  is  easy  to  push  the  closed  scissors 
flat  along  the  uterus  like  a  wedge,  whenever  a  free  point  is 
found ;  then  the  points  are  spread  so  that  the  puncture 
wound  is  broadened  and  deepened.  The  retractor  is  then 
pushed  into  this  gap,  prising  up  the  investing  lamina  of 


FIG.  33. — METHOD  OF  FIXING  THE  PORTIO  VAGINALIS  WITH  THREE  VOLSELLJE. 

tissue  along  with  the  bladder  above  it.  In  this  way  a 
further  segment  of  the  uterine  neck  is  liberated  from  its 
connective  tissue,  and  now  this  part  is  to  be  split  up  the 
middle,  continuously  with  the  first  incision,  up  to  the  point 
marked  by  the  retractor.  New  forceps  are  applied  to  the 
lips  of  the  wound  as  high  as  possible,  or  the  lower  ones  are 
removed  and  replaced  higher  up. 

This  lateral  application  of  the  volsellae  has  the  advantage 
that,  in  spite  of  the  large  resultant  of  their  combined  traction, 


MEDIAN  SECTION  OF  ONE  WALL  OF  THE  UTERUS     125 

the  tissue  grasped  is  not  too  strongly  pulled  on,  for  the 
traction  is  divided  among  the  several  instruments ;  the 
tissue  does  not  tear  out  as  might  happen  if  one  applied  the 
same  force  to  one  single  instrument  placed  in  the  middle 
line. 

Advancing  in  this  manner,  the  whole  anterior  wall  of  the 
uterus  is  gradually  split  up,  when    necessary  clear  to  the 


FIG.  34. — THE  UNROLLING  OF  THE  UTERUS  RESULTING  FROM  SECTION 
OF  ITS  ANTERIOR  WALL. 

fundus  (Fig.  34),  and  the  peritoneum  is  opened  with  the 
scissors  as  soon  as  it  becomes  visible.  One  volsella  is 
applied  above  the  other  each  time  the  sagittal  incision  is 
lengthened,  so  that  these  forceps  are  always  climbing  higher, 
the  bladder  and  ureters  being  meanwhile  securely  protected 
by  the  retractor.  Haemorrhage  is  prevented  by  the  down- 
ward and  outward  traction  upon  the  forceps. 

Often  it  is  not  necessary  to  carry  the  longitudinal  incision 


126  THE  VAGINAL  RADICAL  OPERATION 

of  the  front  wall  as  high  as  the  fundus,  for  a  uterus,  even 
when  twice  as  large  as  normal,  if  not  directly  or  indirectly 
fixed,  can  be  brought  into  the  vagina  as  soon  as  room  is 
made  for  it  by  splitting  and  unrolling  its  lower  segment, 
employing  meanwhile  traction  from  below  and  leverage  for- 
ward, with  the  fingers  or  retractor  passed  behind  the  fundus. 

A  uterus  fixed  merely  by  its  size  becomes  mobile  by  being 
so  unrolled,  and  can  then  be  delivered  conduplicato  corpore 
into  the  vagina,  the  cervix  being  at  the  same  time  pushed 
upward  and  backward  by  means  of  the  forceps  attached  to 
the  portio.  In  certain  cases  as,  for  instance,  uncomplicated 
uterine  hypertrophy  or  pyosalpinx  developed  in  the  ampulla 
of  the  tube,  the  median  section  is  easily  carried  up  as  high 
as  the  fundus  in  a  few  moments,  with  two  or  three  cuts  of 
the  scissors,  and  the  organ  can  then  be  immediately  dis- 
placed forward.  At  other  times,  on  the  contrary,  after  a 
tedious  denudation  and  slow  and  careful  opening  of  the 
anterior  wall,  the  organ  cannot  be  tilted  forward  even  by 
forcible  traction. 

When  the  uterus  is  hypertrophied  beyond  a  certain  point, 
the  unrolling  does  not  even  yet  make  its  delivery  through 
the  vagina  possible.  It  can  then  be  sufficiently  reduced  in 
size  by  the  enucleation  of  fibroids  through  the  sagittal 
incision,  by  excising  V-shaped  masses  from  the  uterine  wall 
(Doyen),  or  by  removing  longitudinal  strips  from  the  wall, 
including  its  whole  length  and  thickness.  But  more  of  this 
later ;  these  are  methods  that  lead  to  morcellement  itself. 

After  the  fundus  comes  into  the  vagina,  the  finger  or 
ovum  forceps  is  to  be  passed  into  the  abdomen,  through  the 
gap  above  the  uterus,  and  the  appendages  seized  and  brought 
out  under  visual  control.  If  the  fixation  can  be  overcome 
during  the  section  of  the  uterus  by  working  through  one  or 
other  cul-de-sac,  the  delivery  of  the  tubes  and  ovaries  is 
made  decidedly  easier.  Otherwise  the  front  wall  is  at  first 
split  completely,  and  then  one  finger  is  introduced  above  the 
fundus,  and,  aided  by  the  fingers  of  the  other  hand  in  the 
posterior  cul-de-sac,  separates  the  adhesions  on  the  posterior 
surface  of  the  uterus  and  about  the  adnexa.  Cysts  and 
abscesses  are  shelled  out  of  their  connections,  and  the 


MEDIAN  SECTION  OF  ONE  WALL  OF  THE  UTERUS     127 

appendages,  together  with  the  fundus,  brought  into  view  by 
means  of  the  ovum  forceps. 

If  the  complete  liberation  of  the  internal  genital  organs, 
that  is,  the  separation  of  the  adhesions  about  the  uterus  and 
the  enucleation  of  the  sclerosed  or  hypertrophied  adnexa 
cannot  be  effected  in  this  manner,  the  splitting  of  the  womb 
must  be  still  further  continued.  One  proceeds  now  to  the 
next  method,  the  total  median  section  of  the  uterus. 

Where,  however,  after  the  above  procedures,  the  uterus  and 
appendages  have  been  delivered  entire,1  the  posterior  cul-de- 
sac  is  to  be  perforated  with  a  clamp  in  case  it  was  not 
opened  during  the  earlier  stages  of  the  operation.  But  by 
no  means  can  it  be  perforated  without  danger  immediately 
after  the  vaginal  incision,  as  is  recommended  by  some  writers 
(Baudron  and  others). 

It  seems  unnecessary  to  make  a  separate  description  of 
the  section  of  the  posterior  wall,  a  procedure  which  is  occa- 
sionally of  service  in  the  rather  infrequent  cases  mentioned 
earlier  in  this  chapter.  The  method  is  just  the  same  as  that 
here  described  ;  the  womb  is  retroverted,  care  being  observed 
previously  to  free  all  its  vesical  and  ureteral  connections,  so 
as  to  avoid  laceration  of  these  organs. 

When  all  the  structures  have  been  brought  into  sight  and 
suitable  pedicles  for  the  same  secured,  one  can  proceed  to 
haemostatic  measures.  Doyen,  the  father  of  this  method, 
begins  at  the  left,  and  applies  from  above  two  long  elastic 
clamps  at  each  side,  each  grasping  the  whole  breadth  of  the 
broad  ligament.  We,  as  usual,  employ  several  forceps, 
beginning  from  below. 

1  When  the  tubes  are  solidly  adherent,  they  are  sometimes  torn  off  at 
the  isthmus  during  these  manipulations.  Still,  they  remain  connected 
with  the  uterus  by  portions  of  the  broad  ligament,  so  that  the  delivery  of 
the  internal  genital  organs  is  practically  complete. 


128  THE  VAGINAL  RADICAL  OPERATION 

CHAPTER  VI. 

COMPLETE    MEDIAN    SECTION    OF   THE    UTERUS. 

IN  describing  the  previous  method,  it  was  stated  that  under 
some  circumstances  the  opening  resulting  from  section  of 
the  anterior  uterine  wall,  and  the  increased  mobility  due  to 
its  unrolling,  do  not  suffice  to  bring  the  bands  of  adhesion 
about  the  uterus  and  the  enlarged  or  atrophied  adnexa 
within  reach.  And  when  the  direct  or  indirect  fixation 
cannot  be  overcome  by  working  from  the  posterior  vaginal 
incision  through  the  firm  cicatricial  tissue,  then  the  section 
of  the  anterior  wall  must  be  continued  through  the  fundus 
and  along  the  posterior  wall,  dividing  the  uterus  into  two 
symmetrical  halves,  and  so  making  a  broader  passage  for 
fingers  and  instruments. 

If  the  fixation  of  the  uterus  be  chiefly  indirect,  due  to 
advanced  changes  in  the  adnexa  with  retraction,  the  divided 
halves  of  the  uterus  will  be  drawn  strongly  toward  the  sides 
of  the  pelvis  by  the  adherent  and  shortened  appendages. 
The  gap  will  then  be  all  the  wider,  and  there  will  be  all  the 
more  room  for  the  enucleation. 

Moreover  this  halving  of  the  organ,  splitting  both  walls  to 
the  fundus,  is  always  to  be  used  when  the  section  of  the 
front  wall  alone  seems  dangerous  or  inconvenient  in  presence 
of  strong  direct  or  indirect  fixation,  or  in  case  of  a  narrow 
vagina.  In  order  to  symmetrically  incise  both  walls  from 
below,  one  must  of  course  be  able  to  get  through  the  posterior 
cul-de-sac  without  endangering  the  rectum.  When  this  has 
been  done,  and  both  walls  of  the  uterus  incised  in  the 
middle  line  beyond  the  internal  os,  the  divided  lower  uterine 
segment  forms  a  /\-snaPed  gap  in  consequence  of  the  traction 
upon  the  sides ;  through  this  breach  the  finger  can  now  free 
the  uterine  body  above  for  the  safer  continuation  of  the 
splitting  process. 

From  these  considerations,  the  total  median  section  of  the 
womb  is  indicated  in  the  extirpation  of  uteri  not  larger  than 
a  man's  fist,  when  complicated  by  bilateral  ovarian  tumours 


COMPLETE  MEDIAN  SECTION  OF  THE  UTERUS       129 

or  inflammatory  or  suppurative  diseases  of  the  adnexa,  with 
marked  pelvi-peritonitic  fixation  of  the  uterus  and  appen- 
dages. It  is  further  indicated  where  the  immobility  of  the 
uterus  is  due  to  the  large  size  of  the  appendages,  which 
cannot  be  sufficiently  diminished  through  the  vaginal  in- 
cision alone,  nor  even  after  the  section  of  the  anterior 
uterine  wall ;  for  instance,  when  the  adnexa  are  the  seat  of 
thick-walled,  multilocular  fluid  collections. 

The  advantages  of  this  total  section  are  so  great  that  in  a 
large  number  of  the  severest  inflammatory  diseases  of  the 
adnexa  and  pelvic  peritoneum  (complicated  pelvic  abscesses), 
one  may  succeed  in  enucleating  the  entire  internal  genital 
organs  without  resorting  to  primary  hsemostasis.  By  this 
method  we  have  been  able  to  prove  that  our  '  enucleation 
procedure '  can  be  executed  in  such  cases,  and  we  have 
therefore  practised  and  developed  it  by  preference. 

Regarded  historically,  the  idea  of  the  median  section 
originated  with  Peter  Miiller,1  who  proposed  it  in  carcinoma 
of  the  uterus,  for  the  easier  ligation  of  the  broad  ligaments. 
After  this,  Quenu2  employed  it  in  vaginal  hysterectomy  for 
pelvic  suppuration.  His  principle  was  to  split  both  walls  at 
the  same  time.  In  his  first  cases  he  applied  a  primary 
ligature  to  the  uterine  arteries  at  the  beginning  of  the 
operation,  but  at  present  he  uses  a  short  heavy  clamp  for 
this  purpose. 

Apart  from  the  mere  division  of  the  uterus,  our  total 
median  section  has  nothing  in  common  with  Quenu's  method. 
Contrary  to  Quenu's  practice,  we  proceed  from  the  incision 
of  the  front  wall,  directly  over  the  fundus  on  to  the  posterior, 
and  remove  not  merely  the  uterus,  but  the  adnexa  as  well, 
and  apply  the  first  clamp  only  after  all  the  parts  have  been 
delivered. 

Our  method  is  as  follows :  First  the  anterior  wall  is 
divided  with  the  scissors  from  the  external  os  to  the  fundus, 
and  the  adhesions  about  the  uterus  separated  as  far  as 
possible.  Then  the  line  of  the  first  incision  is  continued 
backwards  and  downwards,  splitting  the  fundus  and  posterior 

1  Peter  Miiller,  '  Centralblatt  fur  Gynakologie,'  1882,  No.  8. 
-  Quenu,  '  Annal.  de  Gynecol.,'  1892,  Tom.  37. 

9 


130  THE   VAGINAL  RADICAL  OPERATION 

wall  as  far  as  this  can  be  done  without  endangering  the 
neighbouring  structures,  particularly  the  rectum.  The  finger 
or  retractor  introduced  behind  the  fundus  guides  the  in- 
cision and  protects  the  rectum  from  injury.  Strong  volsellae 
are  fixed  on  both  edges  of  the  wound,  and  the  divided  fundus 
pulled  strongly  downwards  and  forwards.  The  field  of 
operation  is  well  exposed,  and  the  scissors  are  guided  by 
the  sense  of  sight  as  they  are  pushed  forwards,  dividing  the 
whole  posterior  wall  down  to  the  cul-de-sac,  the  posterior 
surface  of  the  uterus  having  been  meanwhile  freed  from  its 
perimetritic  adhesions.  If  the  posterior  cul-de-sac  was  not 
opened  at  the  beginning  of  the  operation,  a  closed  clamp  is 
now  to  be  pushed  through  it  from  above,  and  the  wound 
enlarged  by  opening  the  forceps  as  it  is  drawn  back.  The 
portio  is  next  pulled  forward,  and  a  finger  working  up 
through  the  cul-de-sac  from  below,  against  the  assistant's 
finger  or  an  ecarteur  above,  finally  makes  a  safe  way  for  the 
scissors.  The  posterior  wall  of  the  cervix  is  now  split  in 
the  middle  line,  and  the  first  stage  of  the  operation  is 
accomplished. 

The  uterine  segments  retract  laterally  from  each  other, 
springing  out  toward  the  pelvic  wall  on  each  side,  especially 
if  the  appendages  are  shortened  and  adherent,  and  the 
operator's  fingers  have  now  a  broad  free  space.  If  the 
posterior  cul-de-sac,  as  is  sometimes  the  case,  has  resisted 
all  attempts  to  penetrate  into  it,  it  can  now  be  split  in  the 
middle  at  the  same  time  as  the  posterior  wall  of  the  cervix. 
During  this  manipulation  the  rectum  is  to  be  guarded,  the 
uterine  halves  drawn  forward  and  away  from  each  other,  and 
the  whole  field  exposed  to  view  ;  from  the  median  opening,  the 
lateral  portions  of  the  cul-de-sac  are  to  be  incised  at  each  side. 

In  passing,  it  may  be  stated  that  in  the  different  forms  of 
the  vaginal  radical  operation,  the  time  and  manner  of  open- 
ing the  posterior  cul-de-sac  vary  surprisingly.  It  may  be 
opened  by  the  first  incision  in  the  vaginal  vault,  bored 
through  from  here  by  the  finger,  perforated  from  above  by 
a  clamp  after  the  enucleation  of  the  whole  or  the  divided 
uterus,  incised  from  one  side ;  or,  finally,  it  may  be  opened 
from  the  line  of  the  median  section  of  the  womb. 


COMPLETE  MEDIAN  SECTION  OF  THE  UTERUS       131 

The  difficulties  previously  existing  are  now  disposed  of  if 
the  fixation  of  the  uterus  was  chiefly  direct,  i.e.,  perimetritic, 
and  the  adnexa  can  now  be  easily  brought  out.  In  cases 
also  of  indirect  fixation  dependent  on  the  adnexa,  the  latter 
can  now  be  reduced  in  volume  and  enucleated,  a  procedure 
previously  impossible.  In  liberating  firmly-adherent  pus- 


FIG.  35. — THE  DELIVERY  OF  THE  ADNEXA  OF  BOTH  SIDES  AFTER  COMPLETE 
MEDIAN  SECTION  OF  THE  UTERUS. 

tubes  or  ovaries,  both  hands  are  generally  employed,  and  it  is 
a  useful  practical  point,  for  example,  in  enucleating  the  appen- 
dages of  the  left  side,  to  work  with  the  left  index  or  index  and 
middle  fingers  behind,  and  with  the  corresponding  fingers  of 
the  right  hand  in  front  of  the  adnexa.  Commencing  at  the 
isthmus  of  the  tube,  with  moderate  traction  on  the  half  of 
the  uterus  of  the  same  side,  the  adhesions  are  separated,  and 

9—2 


132 


THE   VAGINAL  RADICAL  OPERATION 


the  cysts  opened  and  shelled  out ;  as  the  parts  are  liberated, 
they  are  seized  and  controlled  by  ovum  forceps.  The 
bimanual  manipulation  is  particularly  easy  and  effective 
after  the  median  section  of  the  uterus,  which  gives  a  broader 
and  more  adequate  space.  Generally  the  side  which  seems 
to  be  the  less  involved  is  to  be  first  liberated,  as  in  this  way 
more  room  is  obtained  in  which  to  work  at  the  less  favour- 
able side. 


FIG.  36. — FIRST  POSITION  OF  THE  LEFT  BROAD  LIGAMENT  :   ANTERIOR 
SURFACE  EXPOSED. 

In  this  way  the  whole  of  the  diseased  internal  genital 
organs  are  finally  brought  out  at  the  vulva  in  two  sym- 
metrical halves,  without  the  application,  so  far,  of  a  single 
clamp.1  Besides  the  compression  of  the  edges  of  the 
wound  in  the  uterus  by  the  volsellse,  the  vessels  supplying 
these  structures  are  constricted  by  the  traction  on  each 

1  In  exceptional  cases,  when  the  cervix  is  strongly  fixed  by  adhesions, 
it  may  be  an  advantage  during  the  splitting  operation  to  clamp  the 
uterine  arteries  primarily,  and  amputate  the  cervix.  It  is  then  much 
easier  to  proceed  with  the  median  section  of  one  or  both  uterine  walls. 


COMPLETE  MEDIAN  SECTION  OF  THE   UTERUS       133 


half  of  the  organs ;  and  the  torsion,  combined  with  traction 
(Fig.  35)  must  have  a  similar  haemostatic  effect. 

The  advantage  of  this  method  is  now  shown  in  the  ease 
with  which  the  pedicles  are  formed  and  dealt  with.  If 
desired,  one  may  often  include  the  whole  broad  ligament 
from  its  base  to  the  infundibulo  -  pelvic  ligament  in  one 
single  clamp  applied  external  to  the  suppurating  tube  and 
purulent  ovary.  The  clamps  may  be  so  applied  to  each 
ligament  that  its  anterior  (Fig.  36)  or  posterior  (Fig.  37) 
surface  is  brought  into  view.  During  this  manoeuvre  the 


FIG.  37. — SECOND  POSITION  OF  THE  LEFT  BROAD  LIGAMENT  :   POSTERIOR 
SURFACE  EXPOSED. 

surface  of  the  ligament,  which  is  not  visible,  is  guarded  by 
the  finger  placed  behind  it  (Fig.  38). 

Haemostasis  may  also  be  neglected  for  the  time  being, 
even  when,  as  occasionally  happens,  portions  of  a  cyst  wall 
or  rotten  pyosalpinx  are  torn  off  during  the  enucleation  of 
the  adnexa.  Where  such  an  accident  is  feared,  it  is  always 
better  to  secure  the  tissue  in  advance  by  grasping  it  with  an 
ovum  forceps. 

In  this  way,  in  spite  of  the  soft  condition  of  the  appen- 
dages, it  is  possible  to  bring  out  the  firmly-adherent  ampulla 


'34 


THE  VAGINAL  RADICAL  OPERATION 


of  a  pus-tube,  or  a  portion  of  a  cyst  wall,  and  so  make  the 
operation  a  thoroughly  radical  one. 

However,  we  would  particularly  warn  against  overdoing 
such  efforts.  Naturally,  one  must  dispense  with  the  removal 
of  old  cicatricial  products  which  have  become  united  to  the 
bony  or  muscular  wall  of  the  pelvis.  In  certain  cases  the 
sclerosed  tubes  and  ovaries  themselves  may  through  con- 


FIG.  38. — APPLICATION  OF  THE  CLAMPS  ON  THE  LEFT  SIDE,  IN  THE  POSITION 
SHOWN  IN  FIG.  36.  THE  RIGHT  HALF  HAS  ALREADY  BEEN  CLAMPED 
AND  CUT  AWAY. 

nective  -  tissue  metamorphosis  have  become  inseparably 
fused  with  the  thickened  pelvic  connective  tissue.  So  also, 
in  shelling  out  abscesses  or  trying  to  remove  tissue  shreds, 
one  must  take  into  consideration  the  extent  to  which  the 
bladder  or  intestinal  wall  may  take  part  in  the  formation 
of  the  abscess  wall,  and  how  much  of  their  continuity  is 
affected.  As  previously  explained,  the  sigmoid  flexure  is 


SYMMETRICAL  MORCELLEMENT  135 

the  most  liable  to  be  involved  in  such  processes.  To 
attempt  to  radically  extirpate  the  abscess  or  the  remaining 
shreds  of  tissue  in  such  cases  simply  means  the  formation  of 
a  vesical  or  intestinal  fistula ;  whilst,  on  the  other  hand, 
owing  to  the  extra-peritoneal  mode  of  healing,  these  surfaces 
will  cleanse  themselves  later  and  cast  off  the  shreds  of 
adhesions,  granulation  tissue  and  pyogenic  membrane. 

In  a  small  number  of  cases  of  the  kind  mentioned  earlier  in 
this  chapter  we  have,  like  Quenu,  divided  the  uterus  by  means 
of  corresponding  incisions  along  the  anterior  and  posterior 
uterine  walls.  After  the  explanations  of  this  '  antero- 
posterior  section,'  it  hardly  needs  a  further  detailed  descrip- 
tion. One  thing  is  to  be  emphasized,  and  that  is,  that  in 
this  procedure  (Quenu's)  there  is  a  special  danger  of  injuring 
the  rectum  during  the  mesial  section  of  the  posterior  wall  of 
the  cervix.  When  Douglas'  pouch  is  obliterated  by  firm 
masses  of  scar  tissue,  the  points  of  the  scissors  may  perforate 
a  traction  diverticulum  of  the  rectum,  or  even  wound  an 
adherent  loop  of  small  intestine.  For  this  reason  we  never 
force  this  method  of  total  section  of  the  womb  ;  other  and 
safer  methods  of  morcellation  are  then  to  be  employed. 

Finally,  it  may  be  mentioned  that  in  some  cases  both 
halves  of  the  divided  uterus  may  be  tilted  backwards,  just  as 
it  is  sometimes  done  in  the  case  of  section  of  the  posterior 
wall  alone  (p.  127) ;  for  instance,  when  this  method  of  splitting 
is  employed  for  a  strongly-retroflexed  uterus  with  fibroids. 

Figs.  39,  40,  illustrate  the  method  and  the  efficiency  of 
total  median  section  of  the  uterus. 


CHAPTER  VII. 

MORCELLATING    OPERATIONS    (TRUE    MORCELLEMENT). 

i.  SYMMETRICAL  MORCELLEMENT  WITH  V-,  Y-  AND 
PARALLEL  INCISION. 

WE  divided  the  morcellating  procedures  (see  p.  46)  into  a 
regular  and  an  irregular  morcellement,  the  latter  being  the 
operation  in  the  exact  and  limited  sense  of  the  word.  The 
method  to  be  next  described  represents  the  simplest  of  the 


138  THE  VAGINAL  RADICAL  OPERATION 

regular  or  symmetrical  operations,  and  forms  the  connecting- 
link  between  the  median  section  of  the  uterus  and  true 
morcellement. 

The  indication  for  this  form  of  symmetrical  morcellation 
is  presented  when  we  have  to  deal  with  a  regular  and  sym- 
metrical enlargement  of  the  uterus  due  to  fibroids  or  general 
hyperplasia  of  the  organ,  the  size  being  not  greater  than 
that  of  a  child's  head.  The  mere  section  of  one  or  both 
walls  in  this  case  cannot  reduce  the  size  of  the  organ 
enough  to  allow  of  its  delivery  through  the  natural  obstetrical 
outlet.  The  middle  line  serves  as  the  basis  of  this  dissecting 
procedure,  and  the  lateral  regions,  the  only  ones  where 
haemorrhage  is  to  be  feared,  are  to  be  avoided.  The  V  and 
Y  incisions  are  also  of  use  in  the  case  of  asymmetrical 
enlargement  of  the  uterus  up  to  the  size  mentioned  above. 
The  line  of  direction  of  the  morcellement  does  not  then 
coincide  with  the  sagittal  plane  of  the  body,  as  in  sym- 
metrical hypertrophy,  but  rather  with  that  of  the  uterus. 

Thus,  the  operation  is  chiefly  indicated  for  enlarged  and 
mobile  uteri,  or  such  as  may  be  quickly  rendered  mobile  by 
the  use  of  the  method  ;  fixation  depending  merely  on  the 
volume  of  the  organ  yields,  of  course,  to  this  process  of 
diminution.  It  can  also  be  occasionally  applied  with 
advantage  where  the  uterus  is  directly  fixed. 

One  proceeds  first  with  the  incision  round  the  cervix,  and 
with  its  isolation,  according  to  the  rules  already  given  ;  and 
when  the  bladder  and  urethra  have  been  lifted  up  out  of  the 
way,  the  cervix  is  split  along  the  front  wall  just  as  in  the 
opening  of  the  uterus.  At  this  point  it  is  sometimes 
possible  to  reach  and  enucleate  a  submucous  or  intra-mural 
fibroid  (Doyen's  conservative  vaginal  hystero-myomectomy). 

If  the  enlarged  womb  can  be  drawn  down,  and  the  neigh- 
bouring organs  protected  by  retractors,  the  median  incision 
is  now  to  be  continued  up  to  the  fundus,  and  the  effect  of 
this  opening  of  the  organ  tested  in  regard  to  the  possibility 
of  tilting  the  fundus  forwards.  If  this  is  found  to  be 
difficult,  the  transverse  diameter  is  now  to  be  diminished  by 
resecting,  on  each  side  of  the  sagittal  wound,  regular, 
longitudinal  strips  from  the  whole  length  and  thickness  of 


SYMMETRICA L  MORCELLEMENT 


139 


the  anterior  wall.  The  parenchyma  is  seized  with  volsellae, 
a  strip  is  split  off  with  the  scissors,  and  before  it  is  com- 
pletely severed  new  forceps  are  applied  to  the  sound  tissue 
further  on  (Fig.  41).  Working  in  this  fashion,  the  breadth 
of  the  organ  can  be  evenly  and  very  materially  reduced. 

This  symmetrical  dissection  involves  the  whole  length  and 
thickness  of  the  anterior  wall,  and  is  particularly  efficacious 


FlG.  41. — MORCELLATION  OF  THE  ANTERIOR  WALL  OF  THE  UTERUS  BY 
REMOVAL  OF  VERTICAL  STRIPS. 

when  the  hyperplasia  is  of  the  more  regular  form.  To  this 
must  be  added  a  second  variety  of  regular  morcellation, 
which  consists  in  the  excision  of  wedge-  or  rhomb-shaped 
masses  of  the  uterine  wall,  and  which  is  to  be  adopted  when 
the  hypertrophy  is  localized  more  especially  in  the  fundus^ — 
i.e.,  in  wedge-shaped  uteri. 


140  THE   VAGINAL  RADICAL  OPERATION 


Sometimes  after  a  more  or  less  extensive  splitting  of  the 
front  wall,  the  excision  of  a  single  large  or  small  V-shaped 
mass  suffices  to  give  the  organ  the  desired  mobility.  The 
lines  of  incision  then  present  the  appearance  of  a  Y.  If 
this  simple  variation  proves  insufficient,  one  must  fall  back 
on  the  methods  developed  by  Doyen  and  Segond,  and 
described  by  them  under  various  names.  A  glance  at  the 
illustration  (Fig.  42)  shows  Doyen's  method  —  'ablation 
successive  des  fragments  losangiques  et  cuneiformes.' 

In  this  case  the  sagittal  division  of  the  uterus  is  dispensed 
with  from  the  first,  or,  at  any  rate,  is  given  up  as  ineffectual 
after  section  of  the  cervix. 

In  place  of  this,  when  it  can  be  safely  done,  the  operator 
begins  at  the  middle  of  the  anterior  cervical  lip,  or  at  the 
end  of  the  median  incision  if  one  has  been  made,  and  carries 
two  incisions  upwards  and  outwards,  which  diverge  sym- 
metrically from  the  middle  line,  resecting  in  this  way  a 
V-shaped  mass  from  the  front  wall.  The  wedge  is  severed 
from  its  base  above,  and  the  organ  is  so  diminished  that  not 
infrequently  the  fundus  can  be  brought  through  the  vagina 
without  further  trouble.  When  this  is  not  the  case,  the 
flap  is  to  be  resected  in  form  of  a  rhombus,  the  lips  of  the 
wound  at  each  side  grasped  by  volsellae,  and  further  masses 
of  similar  outline  excised  as  in  the  accompanying  Fig.  42. 
The  forceps  are  placed  gradually  higher,  fixing  the  edges  of 
the  wound,  and  the  part  to  be  resected,  and  drawing  the 
uterus  more  and  more  into  the  vagina,  exactly  as  in  the 
median  section  of  this  organ  previously  described.  The 
entire  mass  removed  from  the  anterior  wall  finally  represents 
a  large  wedge,  with  the  base  above. 

In  Segond's  morcellement  wedge-shaped  pieces  are  cut 
away  from  the  anterior  wall,  each  one  of  which,  contrary  to 
Doyen's  method,  has  its  apex  towards  the  fundus.  Before 
being  resected,  each  wedge  is  fixed  at  its  base  with  a 
volsella.  The  final  result  of  such  a  morcellation  is  shown 
in  Fig  43.  A  A-shaped  mass,  with  its  base  downwards,  has 
been  removed  from  the  anterior  wall. 

In  dealing  with  a  uterus  which  is  both  enlarged  and  fixed, 
after  the  front  wall  has  been  dissected  away  by  one  of  the 


SYMMETRICAL  MORCELLEMENT 


141 


above  methods,  and  more  space  and  some  mobility  of  the 
organ  has  been  thus  obtained,  the  finger  is  to  be  passed 
over  the  fundus,  adhesions  broken  up,  the  appendages 
liberated,  and  all  the  parts  delivered. 

Segond  has  called  his  method  '  central  cuneiform  excava- 


FIG.  42. — DOYEN'S  METHOD  OF  MORCELLEMENT.     (After  Doyen, 
I.e.  Fig.  34,  p.  87.) 

tion,'  in  spite  of  the  fact  that  it  really  has  nothing  to  do 
with  an  excavation,  central  or  otherwise,  nor  with  the  resec- 
tion of  cone-shaped  pieces.  The  true  '  central  cuneiform 
excavation '  comes  under  the  methods  of  irregular  morcelle- 
ment,  and  is  chiefly  useful  in  the  piecemeal  extirpation  of 
fibroids,  as  we  shall  see  farther  on. 


142 


THE   VAGINAL  RADICAL  OPERATION 


The  misunderstanding  arising  from  this  rather  inap- 
propriate name  caused  Segond  to  explain  his  position  in  an 
article  in  which  he  said  :  '  The  expression  "  central  excava- 
tion "  does  not  signify  that  the  uterus  is  excavated  from  its 
centre  towards  the  periphery,  but  rather  from  the  peritoneal 
surface  towards  the  cavity.' 


FIG.  43. — SECOND'S  METHOD  OF  MORCELLEMENT  :   FINAL  STAGE. 

Those  who  use  and  compare  the  different  methods  of 
regular  morcellement,  the  strip-like  resection  of  the  anterior 
wall,  or,  in  suitable  cases,  Doyen's  or  Segond's  procedure, 
will  be  convinced  that  the  execution  of  a  true  geometrical 
division  of  the  organ,  like  that  shown  in  Fig.  42,  is  only 
rarely  practicable. 

In  his  method  Segond  always  ligates  the  uterine  arteries 


SYMMETRICAL  MORCELLEMENT  143 

primarily,  and  the  cervix  is  always  extirpated  before  dis- 
secting away  the  corpus. 

"We  claim,  on  the  contrary  (as  explained  in  Chapter  VI., 
Part  II.),  that  for  us  neither  this  nor  any  other  form  of 
morcellation  stands  in  a  definite  relation  to  any  given  plan 
of  haemostasis.  As  far  as  these  methods  can  be  used  to 
advantage,  i.e.,  as  far  as  they  are  technically  easy  and  with- 
out danger  to  adjacent  organs,  secondary  haemostasis  is 
sufficient  in  the  majority  of  the  cases.  As  soon  as  the 
fixation  of  the  uterus  has  been  overcome  by  the  aid  of  one 
or  the  other  form  of  morcellation,  one  proceeds  just  the 
same  as  in  removing  the  organ  entire,  or  after  the  simple 
median  section ;  the  pedicles  are  formed,  clamped  off,  and 
divided. 

When  the  fixation  is  chiefly  paracervical,  it  is  necessary 
to  secure  the  uterine  arteries  primarily,  and  liberate  the 
cervix  first,  so  that  the  uterus  can  be  drawn  down  and  the 
body  of  the  womb  brought  within  reach.  Occasionally  in 
such  cases,  in  order  to  reach  the  upper  part  of  the  uterus  at 
all,  it  is  necessary  to  amputate  the  cervix  as  soon  as  its 
vessels  have  been  secured.  For  this,  one  of  the  combined 
methods,  to  be  described  later,  is  employed. 

These  methods  of  regular  morcellation,  which  we  have 
mentioned  as  applied  to  the  anterior  uterine  wall,  may  of 
course  be  employed  for  the  posterior  wall  when  this  is  espe- 
cially involved  in  the  hypertrophy  or  new  growth. 

During  this  operation  it  is  absolutely  essential  that  the 
structures  adjacent  to  the  posterior  wall  (rectum,  and  possibly 
adherent  loops  of  gut),  be  separated  with  a  blunt  instrument, 
and  protected  by  the  finger  or  retractor.  Here,  as  in  the 
operation  on  the  front  wall,  strips,  wedge-  or  rhomb-shaped 
masses,  can  be  removed,  or  fibroids  enucleated  from  the 
parenchyma. 


144  THE  VAGINAL  RADICAL  OPERATION 


CHAPTER  VIII. 

BILATERAL  SECTION  OF  THE  UTERUS,  AND  TRANSVERSE 
EXCISION  UNDER  PRIMARY  H^MOSTASIS  (PEAN'S  CLAS- 
SICAL MORCELLEMENT). 

SINCE  this  method  presupposes  the  primary  control  of  the 
vessels,  it  is  for  us  always  a  method  of  necessity,  a  dernier 
ressort,  as  it  were.  Nevertheless  in  many  cases,  including 
some  of  the  most  serious  ones,  it  is  the  only  operation  which 
can  be  employed  to  the  patient's  advantage. 

The  indications  for  this  procedure  include  the  severest 
inflammatory  and  suppurative  diseases  of  the  uterus,  appen- 
dages, and  pelvic  peritoneum,  especially  the  worst  forms  of 
pelvic  suppuration.  It  is  indicated  for  uteri  not  larger  than 
a  man's  fist,  when  the  organs  are  bound  down  by  cicatricial 
fibrous  masses  resulting  from  plastic  pelvic  peritonitis,  so 
that  all  mobility  of  the  organs  is  lost  ;  and  also  when  this 
condition  is  complicated  by  double  pyosalpinx,  ovarian 
abscesses  of  both  sides,  or  multiple  intra-  or  extra-peritoneal 
abscesses  with  or  without  rectal  or  vesical  fistulas. 

Pean's  systematic  morcellement,  which  he  advocated  with 
insufficient  discrimination  for  every  form  of  pelvic  suppura- 
tion, as  well  as  for  carcinoma  of  the  uterus,  is  at  present 
discarded  to  some  extent.  Methods  of  treating  pelvic 
suppuration  have  come  into  use  which,  in  comparison  with 
the  castratio  uterina,  are  simpler,  although  just  as  radical, 
while  morcellation  must  be  excluded  in  dealing  with  uterine 
cancer.  Still,  his  method  is  of  permanent  value  in  the 
treatment  of  the  cases  first  mentioned.  It  has  led  to  the 
development  of  the  other  morcellating  operations,  even 
although  the  principle  of  primary  haemostasis,  which  he  so 
firmly  held  to  in  morcellement,  is  now  only  partially 
adopted. 

Whenever  in  course  of  the  classical  Pean's  operation  it 
becomes  possible  to  enucleate  the  parts  primarily,  we  employ 
a  combined  method,  such  as  Segond's  procedure,  lately 
described  by  Baudron  :  removal  of  the  cervix  after  primary 


PEAN'S  CLASSICAL  MORCELLEMENT  145 

hasmostasis,  and  delivery  of  the  corpus  after  section  of  the 
anterior  wall,  or  after  '  central  conoidal  excavation '  ;  in  this 
way  primary  and  consecutive  haemostasis  are  used  in  com- 
bination. If,  however,  it  is  necessary  to  complete  the 
operation  wholly  according  to  Pean's  method,  the  feature 
which  distinguishes  it  from  all  other  procedures  is  that  at  no 
time  does  one  have  to  deal  with  mobile  or  enucleable  parts. 
Still,  we  maintain  that  for  many  conditions  the  complete 
carrying  out  of  Pean's  method  is  the  only  suitable  and 
practicable  procedure. 

When  the  anterior  and  posterior  surfaces  of  the  uterus 
are  intimately  adherent  to  the  adjacent  structures,  it  is  safer 
for  these  latter  not  to  use  any  cutting  instrument  at  first  in 
the  uterine  parenchyma,  but  only  in  those  portions  of  it 
whose  vessels  have  first  been  secured  under  constant  visual 
control.  By  this  means  haemorrhage  from  such  regions  of 
the  womb  is  out  of  the  question,  and  it  is  now  ready  for 
morcellation  in  its  whole  extent,  while  in  the  piecemeal 
extirpation  of  the  fixed  organ  the  volsellae  would  only 
partially  control  the  haemorrhage.  They  might  compress 
the  vessels,  but  could  not  close  them  by  traction  on  account 
of  the  fixation. 

The  method  is  as  follows :  Volsellae  are  placed,  one  on  the 
anterior  and  one  on  the  posterior  lip,  or  one  is  applied  in 
front  and  two  symmetrically  behind  ;  in  any  case,  the  lateral 
commissures  of  the  portio  should  be  left  free.  This  is 
followed  by  oval  incision  and  isolation  of  the  cervix.  As  it 
is  often  difficult  to  break  through  the  firm  and  strong  para- 
cervical  fibrous  layers,  scissors  or  knife  must  be  freely  used 
in  liberating  the  cervix ;  and  here  especially  is  the  rule  to  be 
observed  always  to  work  directly  against,  or  even  in,  the 
uterine  tissue.  It  must  be  remembered  that  here  there  is 
no  little  danger  of  injuring  the  neighbouring  organs  ;  bladder 
and  rectum  are  fused  to  the  cervix  by  cicatricial  processes, 
and  the  ureters  are  not  only  surrounded  by  indurated  masses, 
but  are  displaced  by  the  retraction  of  the  tissues,  and  often 
drawn  close  against  the  uterine  neck.  Hence  one  must  not 
try  to  forcibly  dislocate  the  bladder  and  ureters  upwards  at 
once  to  the  full  extent  in  the  endeavour  to  reach  the  anterior 

10 


146  THE  VAGINAL  RADICAL  OPERATION 

peritoneal  fold,  nor  should  the  finger  be  forcibly  thrust 
through  indurated  masses  in  the  posterior  cul-de-sac,  even 
if  the  opening  of  cysts  and  abscess  cavities  by  this  manipu- 
lation be  ever  so  desirable.  Very  often,  indeed,  large  multi- 
locular  collections  of  fluid  are  evacuated  in  the  first  attempts 
to  get  through  into  the  pouch  of  Douglas. 

What  we  have  now  to  aim  at  more  particularly  is  to  free 
the  vaginal  mucous  membrane  at  each  side  of  the  cervix  in 
front  and  behind  the  ligaments,  far  enough  to  obtain  an  equal 
space  on  each  side  corresponding  to  the  portion  of  the  cervix 
already  liberated.  This  lower,  first  isolated  part  of  the  broad 
ligament  contains  the  uterine  artery,  and  one  must  make 
sure  that  the  bladder  and  ureters  have  been  pushed  well 
up  out  of  the  way.  In  this  freeing  of  the  broad  ligament, 
rough  boring  or  tearing  manipulation  must  be  avoided,  and 
extreme  caution  and  gentleness  must  be  observed,  not  only 
because  the  bladder  and  ureter  may  be  lacerated,  but  also 
to  avoid  tearing  through  the  larger  vessels.  The  chronic 
inflammatory  processes  in  the  pelvic  connective  tissue  do 
not  leave  the  vessels  unchanged;  arterial  and  peri-arterial, 
phlebitic  and  periphlebitic  processes  may  cause  an  unusual 
degree  of  brittleness  of  the  vessel  walls. 

A  clamp  with  short  stout  blades  is  applied  to  the  exposed 
base  of  the  broad  ligament  at  each  side,  and  the  tissue  at 
once  cut  through  inside  the  forceps.  The  liberated  portion 
of  the  uterine  neck  is  then  cut  upward  with  the  scissors, 
right  and  left  from  the  commissure  in  the  coronal  plane, 
making  in  this  way  an  anterior  and  posterior  flap.  One 
after  the  other  is  then  drawn  forwards,  and  cut  away  hori- 
zontally from  the  uterine  body,  and  a  fresh  volsella  placed 
on  the  middle  of  the  wound  surface  of  each  of  the  stumps. 

In  all  this  cutting  the  haemorrhage  is  practically  nil,  for 
the  vascular  supply  has  been  previously  cut  off  from  each 
transverse  uterine  segment  which  is  to  be  extirpated. 

We  consider  it  better  to  give  the  flaps  an  oblique  instead 
of  a  horizontal  direction  in  front  of  and  behind  the  cervical 
canal.  In  this  way  there  is  fashioned  a  tent-shaped  cavity, 
with  the  apex  above,  while  the  tissue  sloping  downwards  at  a 
sharp  angle  is  better  adapted  for  the  volsella. 


PEAN'S  CLASSICAL  MORCELLEMENT  147 

There  is  now  room  for  further  liberation  of  the  uterus, 
and  the  process  is  to  be  carried  as  high  as  possible  in  front, 
at  the  sides,  and  behind,  in  exactly  the  same  way  as  just 
described.  The  greatest  possible  care  is  to  be  observed  in 
freeing  the  anterior  wall  as  long  as  the  bladder  and  ureters 
have  not  been  entirely  isolated. 

Another  short  heavy  clamp  is  now  to  be  applied  above  and 
inside  the  first,  at  a  height  corresponding  to  the  freed 
portion  of  the  womb,  the  ligament  on  each  side  cut  away 
from  the  uterus  for  a  like  distance,  a  flap  formed  in  front 
and  behind  as  was  done  with  the  cervix,  and  then  this  again 
cut  away  transversely.  Generally  during  the  second  act  the 
anterior  fold  of  peritoneum  comes  into  view  as  a  firm  white 
fibrous  membrane.  It  is  to  be  opened  in  the  usual  manner, 
the  finger  introduced,  and  adhesions  in  the  anterior  cul-de- 
sac  torn  away  and  adherent  loops  of  gut  freed  if  present. 
As  a  rule  the  posterior  cul-de-sac  offers  the  most  serious 
difficulty.  Separating  the  adhesions  between  the  rectum 
and  uterus  carefully  with  the  finger  during  the  formation  of 
each  flap,  it  not  infrequently  happens  that  the  peritoneal 
cavity  is  not  opened  from  here  until  the  fundus  has  been 
cut  away  from  below  (total  obliteration  of  Douglas'  pouch). 

In  completing  the  total  extirpation  of  the  uterus,  the 
further  procedures  are  always  a  repetition  of  the  first :  libera- 
tion of  a  segment  of  uterus  and  ligament,  preventive  clamp- 
ing of  the  latter,  formation  of  anterior  and  posterior  flaps  by 
splitting  the  uterus  up  along  each  side,  and  finally  excision 
of  the  same.  The  incision  and  resection  proceed  part  passit 
until  finally  the  womb,  with  all  its  vessels  safely  secured,  has 
been  so  far  shelled  out  that  only  the  lateral  horns  remain  to 
show  the  way  to  the  adnexa. 

If,  however,  in  the  course  of  this  systematic  resection  the 
fundus  becomes  mobile,  it  is  to  be  at  once  delivered  along 
with  the  appendages  without  further  manipulation.  Other- 
wise the  extirpation  by  this  method  is  usually  completed  in 
three  or  four  acts  with  the  application  of  as  many  clamps  on 
each  side. 

What  is  still  to  be  done  depends  wholly  on  the  condition 
and  position  of  the  adnexa.  It  would  be  unnecessary,  as 

10—2 


148  THE  VAGINAL  RADICAL  OPERATION 

well  as  dangerous,  to  force  a  radical  operation  when  a  dense 
pachypelviperitonitis  is  encountered  in  which  the  uterus 
and  pelvic  peritoneum  are  chiefly  involved,  whilst  the  appen- 
dages are  relatively  little  altered,  or  possibly  totally  atrophied 
and  buried  in  the  pelvic  connective  tissue,  inseparably  fused 
to  it  and  the  pelvic  wall.  Under  such  circumstances  one 
would  only  lacerate  the  pelvic  floor  in  attempting  to  dig 
out  the  adnexa,  and  perhaps  injure  the  ureters  or  intestine 
as  well ;  hence  the  mere  removal  of  the  womb  must  suffice. 
By  this  means,  in  the  first  place,  the  focus  of  the  chronic 
inflammatory  processes,  the  diseased  uterus,  is  eliminated; 
and,  secondly,  with  its  removal  disappears  the  fixed  point  for 
the  firm  adhesions  which  bind  it  to  the  intestines  (more 
especially  the  colon),  and  which  seriously  affect  their  function 
and  mobility. 

But  when  fluid  collections  exist  in  the  appendages  (pachy- 
pyosalpinx,  pyo-ovarium,  intra-  and  extra  -  peritoneal 
abscesses)  the  question  is  different,  for  here  the  radical 
operation  is  not  only  desirable,  but  is  technically  possible  as 
well.  Happily,  the  indications  and  the  feasibility  go  hand  in 
hand. 

Beginning  at  one  horn  of  the  uterus,  the  appendages  are 
brought  down  into  the  space  left  by  the  removal  of  the 
womb,  preferably  taking  first  the  side  which  is  the  easier  to 
enucleate.  Two  fingers  are  introduced  along  the  diseased 
tube,  commencing  at  the  isthmus,  and  this,  together  with  the 
ovary,  is  shelled  out  bluntly,  the  process  being  meanwhile 
aided  by  traction  with  an  ovum  forceps  on  each  successive 
part  as  it  is  freed.  On  account  of  the  clamps  already  in 
place,  this  method  of  enucleation  demands  much  greater 
caution  than  those  previously  described.  Too  rough  mani- 
pulation in  this  limited  space  may  lead  to  loosening  or 
slipping  of  the  clamps  controlling  the  uterine  vessels,  there- 
fore attempts  at  bimanual  enucleation  should  be  discarded 
as  much  as  possible.1 

1  In  a  few  cases,  particularly  in  narrow  vaginae,  after  the  removal  of  the 
uterus,  we  have  joined  the  several  isolated  pedicles  into  one  or  two  larger 
ones.  To  the  outer  side  of  the  clamps  first  put  on,  one  or  two  clamps  are 
applied,  so  that  all  the  small  pedicles  are  grasped  as  one  mass.  In  this 


PEAN'S  CLASSICAL  MORCELLEMENT  149 

If  difficulties  be  met  with,  it  is  much  better  to  expose  the 
abscesses  or  pus-tubes  by  holding  back  the  structures  with 
the  retractors  and  carefully  sorting  the  clamps  ;  then  possibly, 
after  evacuating  their  contents,  one  may  try  to  loosen  and 
bring  out  their  upper  portions.  The  larger  the  mass  of 
diseased  adnexa  adherent  to  the  uterus,  and  the  nearer  they 
lie  to  the  recto-uterine  cul-de-sac,  the  easier  is  their  enuclea- 
tion.  Often  they  can  be  delivered  in  toto.  At  other  times, 
however,  they  can  only  be  got  away  in  larger  or  smaller 
pieces. 

Occasionally  by  the  purely  vaginal  method  only  a  partial 
extirpation  of  the  diseased  tissues  can  be  accomplished,  as, 
for  instance,  when  the  adhesions  lie  more  to  the  sides,  when 
the  inflammatory  products  are  high  up  and  posterior,  or 
retroperitoneal  and  behind  the  sigmoid  flexure,  or,  finally, 
when  they  are  situated  up  against  the  anterior  abdominal  wall. 

In  such  cases  ventral  laparotomy  is  justified,  and  with  its  aid 
must  be  accomplished  that  which  could  not  be  done  per 
vaginam.  After  the  incision  through  the  linea  alba,  the 
purulent  cysts  are  freed  and  ligatured,  as  in  a  primary 
laparotomy,  or  one  or  more  clamps  may  be  passed  through 
the  vagina  and  applied  to  their  pedicles  under  direct  visual 
control.  The  intra-abdominal  ligatures  may  be  cut  short, 
or  they  may  be  used  to  drag  the  stumps  down  into  the 
vaginal  wound.  Sometimes  the  control  of  the  vessels  during 
the  preceding  vaginal  operation  is  so  effective  that  in  the 
ventral  laparotomy  the  adnexa  can  be  shelled  out  of  their 
adhesions  with  no  haemostatic  measures,  and  without  losing 
a  drop  of  blood.  As  soon  as  all  the  diseased  tissues  have 
been  removed,  the  abdominal  wound  is  to  be  closed,  and 
the  vaginal  wound  surface  examined. 

way  one  gains  considerable  space  for  the  enucleation  of  the  appendages. 
The  width  of  the  wound  is  correspondingly  increased  by  the  removal  of 
the  forceps,  securing  in  this  way  a  better  exit  for  the  discharges.  This 
uniting  of  the  pedicles  can  be  practised  in  the  same  way  in  all  the  other 
methods  of  the  vaginal  radical  operation,  especially  when  it  is  desirable 
to  reduce  the  weight  of  the  bundle  of  clamps  after  the  operation.  At  the 
same  time  the  pedicles  are  shortened,  and  large  masses  of  tissue  removed 
which  would  otherwise  have  to  come  away  by  themselves. 


150  THE   VAGINAL  RADICAL  OPERATION 

There  may  be  considerable  parenchymatous  haemorrhage 
from  the  shreds  of  adhesions  and  remnants  of  pyogenic 
membrane. 

Compression  with  a  mounted  sponge  for  a  short  time 
usually  stops  the  oozing,  but  in  other  cases  short  light 
clamps  must  be  applied.  After  the  operation  is  finished, 
the  central  strip  of  gauze  is  to  be  loosely  spread  over  the 
whole  ragged  and  lacerated  wound  surface. 

It  must  be  admitted  that  in  many  cases,  even  after  the 
ventral  has  been  joined  to  the  vaginal  laparotomy,  the 
adnexa  cannot  be  reached,  because  the  intestines  fused 
together  by  the  chronic  general  peritonitis  form  an  impene- 
trable roof  over  the  internal  genitalia.  To  isolate  gut  and 
adnexa  from  each  other,  and  from  the  pelvic  and  abdominal 
walls,  means  nothing  less  than  laceration.  Such  cases 
cannot  be  radically  dealt  with  by  any  method. 

Here,  forced  by  necessity,  one  must  be  content  with  a 
hysterectomy  with  evacuation  and  drainage  of  the  abscesses 
into  the  vagina.  All  the  remaining  recesses  and  spaces 
are  to  be  loosely  packed  with  gauze.  Portions  of  abscess 
walls  must  likewise  be  left  behind  regardless  of  their  extra- 
peritoneal  development,  when  their  capsule  is  in  part  formed 
by  a  hollow  organ  (bladder,  rectum). 

It  is  evident  that  here  the  operation  must  remain  incom- 
plete. So  the  vaginal  radical  operation,  even  in  combination 
with  ventral  laparotomy,  has  its  limits,  and  must,  when 
necessary,  conclude  with  the  removal  of  the  uterus. 


CHAPTER  IX. 

IRREGULAR  MORCELLATION  (TRUE  MORCELLEMENT). 

i.  WHEN  THE  UTERUS  is  NOT  AT  ALL,  OR  BUT  SLIGHTLY, 

ENLARGED. 

THE  method  given  for  bilateral  incision  of  the  uterus  with 
transverse  resection  cannot  be  employed  when  the  uterine 
parenchyma  has  lost  the  firmness  necessary  for  the  shaping 
of  the  individual  portions  to  be  removed ;  for  instance,  in 
inflammatory  oedema  of  this  organ,  found  chiefly  in  pelvic 


IRREGULAR  MORCELLEMENT 


suppuration  following  labour  or  abortion  ;  in  extensive  tubal 
pregnancy ;  and,  finally,  in  many  cases  of  chronic  recurrent 
(so-called  subacute)  pelvic  suppuration. 

We  shall  not  here  enter  into  the  discussion  of  the  indications 
for  hysterectomy  in  suppurative  puerperal  conditions.  Some 
authors  (Richelot)  regard  the  puerperal  softening  and  re- 
laxation of  the  uterine  tissue  as  a  direct  contra-indication 
for  hysterectomy.  We  may  observe,  in  passing,  that  of  two 
cases  which  we  subjected  to  the  vaginal  radical  operation 
on  account  of  complicated  puerperal  pelvic  abscesses,  one 
died,  and  the  other  was  saved  in  spite  of  a  hopeless  prognosis 
before  the  operation.  In  all  cases  of  metritic  softening, 
however,  whether  puerperal  or  not,  the  technical  difficulties 
in  the  way  of  uterine  extirpation  are  unusually  great,  simply 
because  it  is  impossible  to  carry  out  the  plan  of  the  operation 
according  to  one's  own  wishes,  for  the  procedure  must  within 
certain  limits  be  governed  entirely  by  the  consistence  of  the 
organ.  Naturally,  this  applies  as  well  to  the  intended  Pean's 
morcellement,  as  to  all  other  procedures  for  extirpating  the 
softened  uterus. 

The  main  difficulty  lies  as  much  in  avoiding  haemorrhage 
as  in  controlling  it,  for  the  volsellae,  which  in  other  forms  of 
morcellement  exert  their  haemostatic  effect  by  traction  and 
pressure,  are  here  unavailing,  because  traction  simply 
lacerates  the  organ,  while  compression  crushes  the  tissue. 
Moreover,  in  spite  of  all  endeavours  to  protect  the  lateral 
portions  of  the  uterus,  the  tissue  may  be  lacerated,  and  the 
tear  extend  into  the  inflamed  and  highly  vascular  broad 
ligament. 

Under  such  circumstances  one  can  scarcely  give  a  typical 
description  of  such  an  operation  even  if  Pean's  morcellement 
is  to  be  aimed  at  throughout.  Sometimes  it  would  vary  but 
little  from  the  classical  Pean's  operation  ;  sometimes  in  its 
unforeseen  irregularity  it  would  not  resemble  it  in  the  least. 

The  indications  have  already  been  mentioned;  the  softened 
uterus  must  not  exceed  the  size  of  a  man's  fist. 

At  the  very  beginning  of  the  operation,  in  applying  and 
making  traction  upon  the  volsellae,  or  in  denuding  the  cervix, 
it  becomes  evident  that,  in  spite  of  the  ease  with  which  the 


152 


THE  VAGINAL  RADICAL  OPERATION 


oedematous  paracervical  tissue  is  separated,  the  forceps  will 
not  hold,  and  that  the  portio  tears  and  crumbles  away.  The 
same  difficulty  in  getting  a  firm  hold  in  the  tissues  which 
one  meets  with  everywhere  makes  it  impossible  to  resect 
the  uterus  in  a  regular  geometrical  fashion.  It  is  best  to 
dissect  bluntly  with  the  fingers,  keeping  always  to  the  sides, 
for  in  spite  of  all  this  difficulty  one  must  endeavour  to  apply 
the  clamps  regularly  and  evenly,  working  upwards  from  the 
broad  ligament. 

Whenever  the  consistence  of  the  tissue  allows,  the  original 


FIG.  44. — VAGINAL  RADICAL  OPERATION,  WITH  IRREGULAR  MORCELLA- 
TION  OF  A  UTERUS  ONLY  SLIGHTLY  ENLARGED. 

Pean  method  should  be  again  resorted  to.  Not  infrequently, 
however,  and  contrary  to  the  operator's  wishes,  the  flap  on 
the  posterior  or  anterior  wall,  or  both,  tears  out  with  the 
volsellae,  and  one  must  then  be  content  with  small  pieces  of 
uterine  parenchyma  during  the  further  resection  of  the 
organ.  After  primary  control  of  the  vessels  and  the  longi- 
tudinal incision  at  the  sides,  the  two  flaps  are  to  be  dissected 
away  as  small  cubical  or  irregular  fragments,  removed  by 
vertical  or  oblique  incision.  Or  after  primarily  clamping 
the  ligament  and  severing  the  corresponding  segment  of 
the  uterus,  the  bilateral  splitting  can  be  omitted,  and  the 


IRREGULAR  MORCELLEMENT  153 

separated  portion  cut  away  in  all  manner  of  small  polyhedric 
bits.  This  latter  procedure,  which  we  often  employ,  is  well 
illustrated  in  Fig.  44. 

When  necessary,  the  sound  may  be  used  to  show  the 
position  and  direction  of  the  uterine  canal. 

If  the  parenchyma  bleeds  profusely,  haemostatic  forceps 
can  in  some  cases  be  applied  to  the  softened  myometrium 
itself. 

In  this  way,  avoiding  all  rough  traction  and  manipulation 
of  the  clamps  when  they  have  been  once  applied,  after  the 
customary  opening  of  the  peritoneum  in  front  and  behind, 
the  fundus  is  reached  and  delivered  in  the  same  manner. 

The  field  is  now  clear  for  the  enucleation  of  the  adnexa, 
and  this  is  to  be  accomplished  in  the  usual  way. 

2.  WHEN  THE  UTERUS  is  ENLARGED,  OR,  IF  NORMAL, 

IN    COMBINATION    WITH    A    NARROW    VAGINA. 

We  have  now  reached  a  description  of  the  methods  which 
alone  render  vaginal  hysterectomy  possible,  when  the  uterus 
is  larger  than  a  child's  head. 

This  procedure  is  indicated  chiefly  in  single  or  multiple 
fibroids,  from  the  size  of  a  foetal  head  upwards,  with  or 
without  complicating  inflammatory  or  suppurative  diseases, 
or  genuine  tumours  of  the  adnexa.  The  myomatous  uterus 
may  be  pushed  up  into  the  abdominal  cavity,  or  walled  in  by 
surrounding  collections  of  pus. 

In  the  sense  of  its  being  an  indication  for  this  operation, 
the  size  of  the  uterus  is  naturally  a  relative  term,  and  is 
to  be  estimated  by  the  space  relations  between  it  and  the 
vagina.  Hence,  irregular  morcellation  is  employed  when  a 
normal  or  but  slightly-enlarged  uterus  has  to  be  removed 
through  a  narrow  vagina,  other  forms  of  dissection  not 
giving  the  necessary  room  without  attacking  the  adjacent 
structures  (perineal  incision,  etc.).  One  condition  that  is 
necessarily  implied  in  the  indication  is  that  less  mutilating 
conservative  procedures  are  not  applicable  ;  in  other  words, 
the  circumstances  are  such  that  the  uterus  must  be  sacrificed. 
Included  in  the  list  of  conservative  methods  are  the  cases  of 


154  THE  VAGINAL  RADICAL  OPERATION 

enucleation  of  a  fibroma  after  it  has  been  previously  partly 
dissected  away  (morcellating  myomectomy). 

Centra-indications  are :  first,  uterine  fibroids  extending 
beyond  the  navel ;  secondly,  tumours  of  the  body  of  the 
uterus,  whose  development  is  chiefly  or  wholly  subperitoneal. 
In  the  first,  abdominal  or  abdomino-vaginal  hystero-myomec- 
tomy  is  to  be  employed  ;  for  the  second,  simple  abdominal 
resection  or  enucleation ;  or,  finally,  abdominal  total  extir- 
pation. The  latter  is  required  when  a  conservative  pro- 
cedure is  impossible,  and  the  distance  of  the  tumour  from 
the  vaginal  vault  is  so  great  that  no  portion  of  it  can  be 
pushed  or  drawn  down  into  the  vagina. 

In  each  of  these  morcellating  operations,  the  governing 
idea  throughout  is  not  to  hold  fast  to  mathematical  lines, 
but  simply  to  dissect  away  the  whole  mass  in  the  safest  and 
most  convenient  manner  adapted  to  the  case  at  hand.  For 
the  morcellement,  the  uterus  and  the  myoma  or  myomata 
form  one  inseparable  block. 

The  individual  masses  to  be  removed  must  always  cor- 
respond to  the  dimensions  of  the  natural  obstetrical  canal,  so 
that  all  further  injuries  from  dilatation  may  be  avoided. 
The  size  of  each  mass  is  therefore  directly  dependent  on  the 
width  of  the  vagina. 

In  this  procedure  the  volsellae  are  of  paramount  import- 
ance. Their  two-fold  action  in  the  control  of  haemorrhage, 
namely,  by  compression  and  traction,  is  here  specially 
exerted.  Besides  this,  they  have  to  hold  the  fragments 
which  are  about  to  be  removed,  and  at  the  same  time  con- 
trol the  edges  of  the  wound  left  behind,  otherwise  a  flap 
of  the  wound  might  slip  away,  and  from  the  incomplete 
compression  a  dangerous  haemorrhage  might  result.  While 
they  secure  the  old  field  of  operation,  they  mark  at  the 
same  time  the  line  of  the  new  territory  to  be  invaded. 

It  is  quite  immaterial  what  instrument  be  chosen  to  dissect 
the  uterus  or  uterine  tumour,  whether  it  be  the  serre-nceud, 
ecraseur,  or  knife  and  scissors.  For  our  part  we  use  the 
long  scissors  and  knife,  both  straight  and  curved. 

The  difficulty  in  describing  the  forms  of  morcellement  in  a 
systematic  way  consists  manifestly  in  the  countless  varieties 


IRREGULAR  MORCELLEMENT  155 

of  kind,  number,  size,  and  seat  of  the  myomata.  In  this 
respect  there  are  as  many  kinds  of  morcellation  as  there 
are  anatomically  different  conditions  ;  i.e.,  they  are  in- 
numerable. 

Many  who  have  seen  a  number  of  morcellating  operations 
will  be  forced  to  the  conclusion  that  they  have  witnessed 
nothing  more  than  a  mere  laying  hold  and  cutting,  seizing 
with  forceps  and  again  cutting,  etc. — in  short,  a  somewhat 
irregular  and  arbitrary  procedure,  not  depending  on  any 
definite  rules  beyond  patience  and  physical  strength.  And 
yet  such  an  opinion  is  entirely  incorrect.  As  a  matter  of 
fact,  a  mere  aimless  seizing  and  cutting  here  and  there  would 
scarcely  accomplish  the  desired  result ;  on  the  contrary,  even 
here  there  are,  as  stated,  certain  broad  principles  which  must 
be  very  exactly  observed,  and  definite  methods  whose  char- 
acteristics are  quite  different  from  each  other,  although  they 
may  often  be  combined  to  good  advantage. 

CHAPTER  X. 

THE    DIFFERENT    FORMS    OF    IRREGULAR    MORCELLEMENT 
EMPLOYED    ON    THE    ENLARGED    UTERUS. 

IN  classifying  these  procedures  according  to  the  kind  of 
hsemostasis  employed,  three  groups  of  operations  are  to  be 
distinguished,  namely :  those  in  which  the  hsemostasis  is  pre- 
ventive, those  in  which  it  is  consecutive,  and  those  in  which 
the  two  procedures  are  combined.  The  relations  between 
morcellement  and  hsemostasis  have  been  previously  referred 
to  (see  p.  51).  We  stated  there  that  morcellement  and 
preventive  haemostasis  have  as  little  relation  to  each  other  as 
have  morcellement  and  the  clamp  method.  Wherever  it  is 
possible  in  these  morcellating  operations,  we  adhere  to  the 
principle  of  consecutive  control  of  the  vessels,  pushing  directly 
into  the  centre  of  the  mass  to  be  extirpated,  avoiding,  mean- 
while, the  vascular  periphery  of  the  tumour  and  the  lateral 
portion  of  the  uterus.  The  leading  aim  is  to  proceed  at  once 
with  the  removal  of  masses  wherever  it  is  most  convenient, 
and  then  deliver  and  pediculate  the  remaining  parts  without 


156  THE   VAGINAL  RADICAL  OPERATION 

first  securing  the  vessels,  the  haemostasis  therefore  following, 
and  occupying  a  secondary  place. 

In  a  second  group  of  cases  the  vessels  must  be  clamped 
primarily  ;  such  are  the  cases  in  which  a  myomatous  uterus 
is  immobilized  directly  by  the  tumour  itself,  or  by  perimetritic 
adhesions,  or  indirectly  by  the  diseased  adnexa  ;  in  these  the 
fixation  remains  unchanged  up  to  the  end  of  the  hysterectomy, 
no  matter  how  much  of  the  lower  segment  may  have  been 
cut  away  under  preventive  clamping. 

The  cases  which  demand  primary  haemostasis  during  the 
whole  of  the  operation  are  infrequent,  while  those  in  which 
the  mixed  form  is  required  are  quite  common.  By  the  mixed 
form  are  meant  the  cases  in  which  preventive  securing  of  the 
vessels  is  necessary  only  up  to  a  certain  point  in  the  opera- 
tion, after  which  the  organs  become  mobile,  and  can  then  be 
delivered  primarily.  This  method  of  haemostasis  comes  into 
use  in  operations  where  the  fixation  is  gradually  overcome 
by  separating  the  adhesions,  or  by  further  morcellement  after 
the  normal  or  myomatous  cervix  has  been  resected  ;  also 
where  a  large  myoma  of  the  body  can  be  so  cut  away  after 
the  removal  of  the  uterine  neck  that  the  fundus,  now  reduced 
in  volume,  can  be  delivered  into  the  vagina. 

Sometimes,  however,  the  operation  must  begin  at  once 
with  this  morcellation,  where,  for  instance,  one  has  to  deal 
with  a  large  cervical  tumour  or  tumours  lying  in  front  of  or 
behind  or  at  the  side  of  this  portion  of  the  uterus,  or  where 
a  segment  of  a  submucous  fibroid  already  occupies  the  cervix, 
widely  distending  the  canal. 

Each  of  the  three  groups  of  morcellating  operations  may 
be  further  subdivided  into  two  minor  classes  :  morcellation 
by  means  of  centripetal  resection,  and  morcellation  by  means 
of  centrifugal  excavation.  In  the  first  group,  wedge-shaped 
masses  are  resected  from  the  parenchyma  or  periphery  of  the 
mass,toward  the  centre.  In  the  second,  the  tumour  is  excavated 
or  bored  out  from  the  middle,  Segond's  'central  excavation '  in 
the  proper  sense  of  the  word.  As  a  variety  of  this  method 
is  to  be  reckoned  the  enucleation  of  fibroids,  either  whole  or 
partially  dissected  by  one  of  these  two  methods.  It  is  obvious 
that  the  latter  form  of  morcellement  is  the  one  to  be  em- 


IRREGULAR  MORCELLEMENT  157 

ployed  on  the  uterus  whenever  possible,  and  that  during  the 
dissection  one  should  endeavour  to  cut  away  as  large  masses 
as  possible. 

The  centripetal  method  is  really  nothing  else  than  a 
modified  form  of  the  morcellation  described  under  the  V-,  Y-, 
and  parallel  incision. 

The  size  and  position  of  the  tumours  do  not  generally  allow 
of  a  symmetrical  plan  of  incision  definitely  repeated,  with  the 
resection  of  masses  of  regular  size  and  shape.  A  long  scissors 
or  knife  is  used,  and  irregular  blocks  are  cut  out  one  after 
the  other  in  different  wedge-like  forms,  until  finally  the  whole 
mass  has  been  reduced  to  the  size  necessary  for  its  delivery. 
The  dissection  of  the  tumour  or  uterus  begins  at  the  exposed 
surface,  just  as  in  the  symmetrical  morcellement,  and  here 
also  the  incisions  are  not  always  carried  through  the  whole 
thickness  of  the  tumour  or  myometrium. 

Just  where  one  must  begin  depends  wholly  on  the  seat  of 
the  tumour,  whether  the  anterior,  posterior  or  lateral  aspect 
of  the  uterus  is  to  be  cut  away,  whether  the  tumour  is  to  be 
attacked  from  its  peritoneal  surface,  or  whether  its  periphery 
can  be  reached  after  previously  splitting  the  myo-  or  endo- 
metrium,  in  the  latter  case  working  within  the  uterine  cavity, 
through  the  mucosa. 

The  technique  of  the  centripetal  method  consists  in  bring- 
ing the  surface  of  the  mass  into  view,  freeing  it  from  all 
connections  with  adjacent  organs,  and  then  commencing 
work  by  resecting  a  large  wedge  of  the  tumour  with  the  long 
knife  or  scissors  (Fig.  45).  Volsellas  are  placed  on  the  edges 
of  the  wound  immediately  after  the  incision,  so  as  to  avoid 
the  danger  of  the  stump  retracting  and  becoming  lost.  In 
beginning  on  the  serosa,  one  may  at  the  same  time  have  to 
free  the  tissue  in  the  grasp  of  the  forceps  from  adhesions  to 
neighbouring  organs.  The  edges  so  fastened  are  pulled 
downward,  a  fresh  portion  of  the  tumour  is  brought  into 
the  vagina  by  forceps  applied  higher,  and  this  piecemeal 
extirpation  is  continued  in  the  same  way,  resecting  wedge- 
or  cone-shaped  masses  until  the  stump  is  small  enough  to 
pass  the  vaginal  outlet. 

In  distinction  to  this  form  of  morcellement,  in  which  the 


1 58 


THE  VAGINAL  RADICAL  OPERATION 


tumour  is  attacked  from  its  periphery,  the  second  method, 
Segond's  '  excavation,'  begins  with  the  central  portion  of  the 
tumour.  In  this  a  crater  is  formed  which  is  continually 
enlarged,  undermining  the  periphery,  and  finally  bringing  it 
to  collapse.  In  some  cases,  after  clearing  out  the  inner 
portions,  the  whole  organ  is  reduced  to  a  loose  movable  sack 
resembling  the  eviscerated  foetal  body.  The  base  of  the 


FIG.  45.— CENTRIPETAL  MORCELLEMENT  OF  A  FIBROID  OF  THE  BODY 
OF  THE  UTERUS. 

On  the  left  side  the  cervix  has  been  separated  from  the  broad  ligament ;  and 
here  three  preventive  clamps  have  been  applied. 

conical  cavity  is,  of  course,  directed  towards  the  periphery, 
hence  the  first  incision  must  begin  at  the  other  surface  of 
the  tumour. 

Thus,  in  the  central  excavation  the  details  of  the  procedure 
consist  simply  in  the  digging  out  of  a  hollow  cone,  whose 
apex  is  directed  toward  the  middle  of  the  tumour  ;  the  base 


AVOIDANCE  OF  HAEMORRHAGE  159 

is  begun  first,  and  forceps  are  then  placed  on  the  edge  of  the 
circular  incision.  Then  one  or  two  new  forceps  are  placed 
deeper  in  the  cavity,  and  a  further  segment  is  cut  away 
towards  the  centre  of  the  mass.  The  volsellse  are  again 
applied,  fresh  portions  of  the  tumour  are  brought  into  view 
and  corresponding  wedges  and  cones  excised,  and  canals  and 
furrows  scooped  out  and  again  reunited.  One  mass  of 
muscular  tissue  is  removed  after  the  other,  working  always 
in  the  intramural  and  subperitoneal  regions. 

The  size  of  these  blocks  of  tissue  depends  wholly  on  the 
thickness  of  the  uterine  wall. 

Some  operators  employ  trephine-like  instruments  of  various 
construction  for  this  boring  and  excavating  process. 

That  these  two  forms  of  morcellement  are  often  combined 
is  readily  understood  from  the  nature  of  the  thing.  Not 
infrequently  after  the  central  excavation,  it  is  possible  to 
bring  the  more  or  less  enlarged  uterus  forwards  by  traction 
on  the  volsellae.  To  further  displace  it  into  the  vagina,  it 
may  be  necessary  to  reduce  it  still  further  by  cutting  away 
another  piece  or  two  from  its  exposed  periphery,  thus 
changing  over  to  the  centripetal  irregular  morcellement. 


CHAPTER  XI. 

THE    AVOIDANCE    OF    HAEMORRHAGE    AND    INJURY   TO    NEIGH- 
BOURING   ORGANS    DURING    MORCELLEMENT. 

THE  chief  dangers  in  all  these  morcellating  operations  are 
haemorrhage  and  injury  of  the  adjacent  structures. 

In  regard  to  the  latter,  one  must  hold  strictly  to  the 
general  rule,  freeing  the  bladder  and  ureters  completely 
from  the  lower  uterine  segment  whenever  it  is  possible, 
before  beginning  the  morcellement ;  and  where  difficulties 
are  encountered  in  this  line,  the  urinary  organs  should  be 
most  carefully  guarded  by  retractors.  Only  after  the  peri- 
toneum is  opened  can  this  vigilance  be  relaxed,  although  the 
exact  time  at  which  this  is  accomplished  is  in  itself  indefinite, 
and  varies  according  to  the  relations  of  the  individual  cases. 
The  method  of  opening  the  posterior  cul-de-sac  is  governed 


160  THE  VAGINAL  RADICAL  OPERATION 

by  the  rules  previously  given,  modified  always  by  the 
anatomical  conditions  present.  It  sometimes  happens  also 
that  this  incision  may  be  one  of  the  later  acts,  in  fact  quite 
the  last  act,  of  the  operation. 

The  great  danger  of  injuring  the  urinary  organs  when  the 
portio  is  absent — from  atrophy,  malignant  erosion,  or  ampu- 
tation— may  be  still  further  increased  by  myomata  in  the 
lower  segment  of  the  womb,  causing  displacement  of  bladder 
and  ureters.  In  such  cases  it  is  advantageous  and  much 
safer  to  work  at  first  chiefly  upon  the  posterior  wall  of  the 
uterus.  In  the  absence  of  the  portio,  such  unfavourable 
conditions  may  be  present  with  reference  to  injury  of  the 
adjacent  organs  that  from  this  cause  alone  one  must  some- 
times dispense  with  a  vaginal  operation. 

How  the  neighbouring  organs  may  be  endangered  by 
fibroids  is  aptly  shown  by  one  of  Chrobak's  cases  published 
lately  by  Fabricius,  in  an  operation  for  a  myoma  situated  in 
the  posterior  wall  of  the  cervix  :  the  left  ureter  had  to  be 
followed  into  the  tumour  and  liberated  for  a  distance  of 
7  cm. 

The  danger  of  haemorrhage  only  occurs  when  one  works 
too  close  to  the  lateral  portions  of  the  uterus,  thus  ap- 
proaching the  larger  vessels  of  the  ligament,  or  when  one 
neglects  to  secure  the  stump  against  retraction  during 
morcellement.  As  so  often  mentioned,  the  volsellae  here 
fulfil  their  important  haemostatic  function  in  a  most  excel- 
lent manner  through  traction  and  compression,  and  there- 
fore the  operator  is  always  safe  from  haemorrhage  as  long  as 
he  has  the  uterus  under  his  control. 

In  morcellement  it  may  be  laid  down  as  a  rule,  always  to 
secure  the  edges  of  the  wound  each  time  with  the  fixation 
forceps  before  cutting  away  the  portion  to  be  extirpated. 
In  case  they  cannot  be  applied  in  the  identical  place,  a  new 
position  is  to  be  sought  for  higher  up,  and  a  firm  hold  here 
obtained. 


COMBINED  METHODS  161 

CHAPTER  XII. 

COMBINED    METHODS. 

THE  foregoing  classification  of  the  vaginal  radical  opera- 
tion according  to  its  different  methods  is  not  merely 
theoretical,  but  is  really  based  on  our  experience  of  a  series 
of  470  operations.  Those  who  have  at  their  command  the 
various  methods  described,  will  in  every  case  of  vaginal 
extirpation  be  able  to  master  all  the  difficulties  encountered. 
Naturally,  one  is  sometimes  obliged  to  employ  a  combination 
of  these  different  forms  of  extirpation — that  is,  to  resort  to  a 
mixed  procedure.  Here,  also,  the  guiding  principle  is  the 
use  of  preventive  hsemostasis  and  secondary  enucleation 
only  as  a  method  of  necessity.  In  all  cases  the  aim  is  to 
form  the  pedicles  under  visual  control,  and  secure  them 
secondarily. 

Under  preventive  haemostasis  we  have  often  first  sacrificed 
the  cervix,  extirpating  it  entire,  or  after  section  of  one  or 
both  walls.  Then,  after  breaking  up  the  fixation,  which  is 
here  chiefly  pericervical,  the  stump  becomes  more  mobile, 
and  the  rest  of  the  womb,  with  the  adnexa,  may  be  delivered 
entire  or  after  section  of  one  or  both  walls,  or  after  morcella- 
tion  with  the  Y  incisions. 

Fig.  46  shows  the  internal  genital  organs  removed  accord- 
ing to  a  mixed  procedure  :  the  cervical  vessels  secured 
primarily,  the  anterior  cervical  wall  split,  and  the  uterine 
neck  then  amputated,  followed  by  total  median  section  of 
the  body  of  the  uterus. 

Those  operations  in  which  the  vaginal  and  abdominal 
methods  of  extirpation  are  united,  are  mixed  procedures  in 
an  entirely  different  sense  from  the  ones  in  which  different 
vaginal  methods  are  combined.  Abdominal  laparotomy  is 
combined  with  vaginal  hysterectomy  in  order  to  complete 
the  radical  operation,  or  else  it  precedes  the  extirpation  of 
the  organs  per  vaginam — vagino-abdominal  or  abdomino- 
vaginal  radical  operation. 

With  regard  to  the  latter,  the  operation  is  begun  with  the 

II 


1 64  THE   VAGINAL  RADICAL  OPERATION 

incision  through  the  linea  alba,  really  not  for  technical,  but 
rather  for  diagnostic  purposes  (duplicity  of  organs,  dissemina- 
tion of  malignant  tumours,  etc.).  After  the  belly  is  opened 
and  the  indication  for  a  vaginal  radical  operation  established, 
this  primary  ventral  incision  can  be  utilized  for  freeing  the 
uterus  and  adnexa  from  adhesions  under  direct  visual  control, 
making  the  organs  mobile  for  the  vaginal  extirpation. 

After  liberating  and  shelling  out  the  appendages,  one  can 
ligature  and  remove  the  diseased  organs  just  as  in  a  primary 
ventral  laparotomy,  without  regard  to  the  proposed  vaginal 
extirpation  which  is  to  follow.  In  some  cases  the  vaginal 
hysterectomy  is  in  this  way  greatly  simplified. 

In  the  case  illustrated  by  Fig.  47,  the  diagnosis  was  made 
of  a  large  unilateral  (right)  suppurating  ovarian  cyst  lying 
mainly  in  front  of  the  uterus,  and  against  the  abdominal 
wall.  The  extirpation  was  begun  with  the  ventral  incision. 
The  tumour  was  found  to  be  a  gigantic  tubo-ovarian  abscess, 
and  on  the  other  side  an  extensive  pelvi-peritonitis  with  a 
pyosalpinx  was  found,  and  the  vaginal  radical  operation  was 
then  decided  upon.  In  the  endeavour  to  bring  the  right  tumour 
up  into  view,  it  was  loosened  from  its  surroundings,  and 
could  be  shelled  out  and  removed  entire.  The  ventral  wound 
was  closed,  and  the  uterus,  which  could  now  be  removed  in 
one  mass  (without  morcellation),  was  extirpated  through  the 
vagina  along  with  the  adnexa  of  the  left  side. 

Had  the  vaginal  extirpation  been  primarily  adopted  in  this 
case,  a  much  more  complicated  method  (morcellement)  would 
have  had  to  be  employed. 


PART    III. 

THE   AFTER-TREATMENT. 


CHAPTER  I. 

AFTER-FEEDING — REGULATION    OF    BOWELS   AND    BLADDER — 
TEMPERATURE — SECONDARY    HEMORRHAGE. 

THE  measures  which  follow  every  vaginal  radical  operation 
until  the  patient  is  placed  in  bed  have  been  described  (Part  I., 
Chapter  III.).  The  bed  has  been  previously  warmed  by  hot- 
water  bottles.  After  operations  of  unusual  duration  or 
severity,  and  especially  in  the  case  of  anaemic  patients,  as 
in  myoma  or  carcinoma,  we  employ  the  usual  stimulants  : 
several  hypodermic  injections  of  ether  and  camphor;  sub- 
cutaneous or  rectal  injection  of  normal  salt  solution ;  or 
brandy,  hot  tea  or  coffee  in  small  doses  by  the  mouth. 

Otherwise  nothing  is  given  the  patient  during  the  first  five 
hours,  except  a  little  water  for  rinsing  the  mouth.  For  the 
thirst  and  nausea  a  small  cloth  moistened  with  dilute  vinegar 
is  laid  over  the  mouth.  After  this  time  she  receives  a  sip  of 
cool  coffee  from  time  to  time  ;  for  inordinate  thirst  or  nausea, 
small  pieces  of  ice. 

We  have  often  persuaded  intelligent  patients  to  swallow 
nothing  at  all  during  the  first  twenty-four  hours,  with  the 
certain  result  that  vomiting  was  entirely  absent. 

Vomiting  immediately  after  the  operation  occurs  relatively 
seldom,  in  many  cases  not  at  all.  Later,  however,  during 
the  first  and  second  day,  it  is  not  uncommon. 

If  the  twenty-four  hours'  abstinence  cannot  be  enforced, 


1 66  THE  VAGINAL  RADICAL  OPERATION 

one  may  give  a  little  water  with  red  wine  during  the  first 
night,  and  on  the  following  morning  coffee  with  a  little  milk. 
For  breakfast  and  dinner  we  allow  oatmeal  gruel  also,  in  the 
afternoon  coffee  and  milk,  in  the  evening  a  little  weak  soup. 
Except  in  the  case  of  weak  and  debilitated  patients,  we  usually 
dispense  with  alcoholic  preparations,  such  as  wine,  champagne, 
and  cognac.  On  the  third  day  the  same  diet  as  just  given. 

In  the  ordinary  course,  flatulence,  borborygmi,  and  ab- 
dominal pain  begin  on  the  third  day.  Infusion  of  caraway, 
peppermint,  or  valerian  relieves  the  flatus,  which,  as  a  rule, 
is  got  rid  of  during  the  third  day  or  night.  The  pain  due 
to  this  gaseous  distension  is  satisfactorily  met  by  placing 
on  the  abdomen  hot  or  cold  compresses,  or  the  ice-bladder, 
according  to  the  individual  preference. 

On  the  fourth  day  the  diet  is  the  same  as  on  the  second 
and  third,  or,  if  the  general  condition  is  exceptionally  good, 
soft  biscuits  or  rusks.  On  the  fifth  and  sixth  day  bouillon 
for  dinner,  with  rusks  or  biscuits. 

The  bowels  often  move  spontaneously  on  the  fifth  day  ;  if 
there  is  severe  rectal  tenesmus,  it  is  relieved  by  an  injection 
of  warm  water.  In  any  case,  however,  the  patient  receives 
on  the  morning  of  the  seventh  day  two  tablespoonfuls  of 
castor-oil,  given  in  beer  foam  or  hot  coffee.  During  the 
further  convalescence  care  is  taken  to  secure  a  regular  action 
of  the  bowels. 

From  the  seventh  day  onwards  the  convalescent  receives 
the  usual  light  and  easily-digested  diet — coffee,  milk,  bouillon, 
oatmeal  gruel,  white  bread,  rusks,  chicken,  calf's  brain,  fish, 
roasted  potato,  and  stewed  fruit. 

Vomiting,  if  it  occurs  at  all,  generally  ceases  when  the 
tympanites  is  relieved — that  is,  on  the  third  or  fourth  day. 
Occasionally  at  this  time  alarming  symptoms  of  ileus  occur, 
marked  by  vomiting,  distension  of  the  belly,  colicky  pains, 
and  weak  pulse.  In  certain  cases  the  removal  of  the  gauze 
strips  from  the  vagina  suffices  to  allay  these  stormy  symp- 
toms. At  other  times  the  disturbed  intestinal  tract  can  be 
restored  to  its  normal  condition  by  rectal  injection  or  flushing 
of  the  colon.  For  ordinary  vomiting,  as  well  as  for  obstinate 
hyperemesis,  washing  out  the  stomach,  repeated  if  neces- 


THE  AFTER-TREATMENT  167 

sary,  has  rendered  us  very  valuable  service.  In  spite  of  the 
unpleasant  nature  of  this  manipulation,  the  patients  are 
always  so  much  relieved  by  it  that  of  their  own  accord  they 
frequently  demand  its  repetition.  Several  times  in  obstinate 
vomiting,  on  the  fourth  or  fifth  day,  it  has  been  observed 
that  fluids  were  all  rejected,  while  solid  food,  such  as  biscuits 
and  rusks,  was  well  retained. 

This  pseudo-ileus  is  probably  due  to  fresh  and  weak 
adhesions,  and  incarceration  of  intestinal  loops  in  the  neigh- 
bourhood of  the  wound,  which  are  broken  up  again  by 
peristalsis,  or  by  the  filling  of  the  colon  with  water  (injection, 
irrigation).  During  the  remainder  of  convalescence,  here  as 
after  every  case  of  major  operation,  vomiting  due  to  errors 
of  diet  is  much  more  readily  started  than  controlled. 

But  taking  it  altogether,  the  unpleasant  symptoms  arising 
from  the  intestinal  tract  are  much  less  than  those  after 
abdominal  laparotomy  for  inflammatory  affections ;  and 
besides  this,  the  whole  course  of  recovery  is  much  more 
rapid,  whilst  post-operative  shock  is  practically  absent.  After 
the  bowels  have  been  evacuated,  it  is  often  difficult  to  keep 
the  patient  longer  in  bed. 

Pain,  which  occurs  in  most,  though  not  in  all  cases,  is 
treated  by  hypodermic  injections  of  morphia.  As  soon  as 
the  patient  awakes  from  the  anaesthesia  and  complains  of  pain, 
she  receives  a  hypodermic  injection  of  gramme  0*01  (-f  grain). 
Further  injections  are  given  as  required,  and  generally 
gramme  o-03(J  grain)  suffices  for  the  first  twenty-four  hours. 
In  ordering  the  quantity  to  last  during  the  night,  we  have 
found  it  more  serviceable  to  divide  it  into  two  doses  of  TV  grain 
each  than  to  give  the  whole  at  one  time.  It  is  scarcely  ever 
necessary  to  continue  the  drug  beyond  the  first  or  second  day. 

To  damn  the  whole  clamp  method  as  a  '  torture,'  on  account 
of  the  pain  following  the  operation,  is  nothing  less  than  an 
empty  fiction;  as  Richelot  rightly  says:1  '  C'est  faire  un 
veritable  roman  que  de  decrire  comme  un  supplice  Poperation 
nouvelle.' 

The  patient  is  catheterized  as  long  as  the  forceps  are  left 
on ;  either  the  permanent  catheter  is  left  in  the  bladder 

1  L.  G.  Richelot,  '  Archiv.  generates  de  Me"decine,'  Juin,  Juillet,  1893. 


1 68  THE  VAGINAL  RADICAL  OPERATION 

until  the  clamps  are  removed,  or  else  the  urine  is  drawn  off 
with  a  long  metal  catheter  every  six  hours.  Many  patients 
have  surprised  us  by  being  able  to  urinate  spontaneously  in 
the  course  of  the  first  day.  The  reason  that  the  urine  is 
artificially  drawn  off  in  all  cases  during  the  time  the  clamps 
remain  is  principally  to  avoid  the  pulling  about  and  moving 
of  the  clamps  while  the  pelvis  is  being  lifted  on  to  the  bed- 
pan or  other  receptacle.  Only  in  the  most  exceptional  cases 
is  it  necessary  to  use  the  catheter  a  day  or  two  after  the 
clamps  are  taken  away. 

Contrary  to  the  practice  of  other  operators,  we  have  often 
removed  the  clamps  after  the  first  twenty-four  hours.  But 
although  we  have  never  known  this  early  removal  to  be 
followed  by  any  haemorrhage  worth  mentioning,  as  a  rule 
we  still  leave  the  forceps  in  place  forty-eight  hours. 

The  clamps  are  removed  with  the  patient  in  bed  ;  the  only 
change  in  her  position  is  that  the  thighs  are  raised  and  the 
knees  separated  a  little.  The  surgeon  stands  at  the  right 
side  of  the  bed,  and  passes  his  left  arm  under  the  patient's 
right  knee,  lifting  the  instruments  gently  from  below.  Then, 
with  the  right  hand  between  the  patient's  thighs,  one  clamp 
after  the  other  is  unlocked,  and  after  waiting  a  moment  with 
each  one,  so  as  to  relock  it  if  necessary,  it  is  pulled  away 
with  a  cautious  twisting  movement. 

If  in  occasional  cases  there  is  a  slight  trickling  of  blood 
from  the  vagina,  the  introduction  of  a  cotton-wool  tampon 
within  the  vulva  is  generally  sufficient  to  stop  it.  If  it 
persists  in  spite  of  this,  it  is  sometimes  necessary  to  bring 
the  patient  across  the  bed,  and,  after  removal  of  the  gauze 
from  the  vagina,  to  seek  out  the  bleeding-points  and  clamp 
them  again.  The  bleeding  in  such  cases  comes  from  the 
paracervical  plexus  of  veins,  or  from  the  incision  in  the 
posterior  vaginal  wall.  After  this  renewed  clamping,  gauze 
is  introduced,  and  the  forceps  left  in  place  twenty-four  hours 
longer.  We  would  particularly  warn  against  a  mere  gauze 
tamponade  in  such  cases,  for  it  may  change  the  external 
bleeding  into  an  internal  and  invisible  one. 

Frequently  one  of  the  lateral  gauze  strips  is  pulled  out 
with  the  clamps  when  they  are  removed.  In  reference  to 


THE  AFTER-TREATMENT  169 

the  others,  more  particularly  the  central  one,  we  have  de- 
cided after  many  experiments  to  leave  them  in  place  until 
the  evening  of  the  fifth  day.  They  are  taken  out  before  this 
time  only  in  case  symptoms  of  obstruction  develop,  some- 
times on  the  fourth,  or  even  third,  day. 

It  is  yet  to  be  determined  whether  the  use  of  the  gauze  for 
drainage  during  these  five  days  is  really  of  such  importance, 
and  we  think  it  is  probable  that  this  exact  length  of  time 
may  be  varied  to  some  extent  without  injury  to  the  patient. 
Probably  the  chief  function  of  the  gauze  consists  in  its 
action  as  an  irritant  to  the  whole  wound  surface,  causing  its 
rapid  encapsulation.  Doyen,  for  instance,  who  in  some 
cases  removes  all  the  strips  within  twenty-four  hours,  has 
just  as  good  results  as  Richelot,  who  usually  leaves  cotton- 
wool tampons  in  the  vagina  for  seven  or  eight  days. 

We  have  but  seldom  seen  haemorrhage  following  the  re- 
moval of  firmly-adherent  gauze,  either  immediately  or  after 
several  hours.  Such  bleeding  would  be  easily  checked  by 
introducing  a  fresh  strip.  There  is  no  fear  now  that  this 
manoeuvre  will  change  the  external  into  an  internal  haemor- 
rhage, because  by  the  fifth  day  the  abdominal  cavity  is 
already  closed  off.  We  consider  cold  irrigation  as  a  styptic 
unnecessary,  and  a  waste  of  time ;  we  abhor  perchloride  of 
iron  here  as  everywhere  else. 

We  do  not  regard  elevation  of  temperature  during  the 
first  few  days  as  an  indication  for  the  early  removal  of 
the  gauze.  An  evening  temperature  a  few  points  above 
100°  F.  (38°  C.)  is  the  rule  in  the  first  week,  and,  indeed, 
sometimes  it  reaches  102°  F.  (39°  C.),  in  cases  whose  progress 
is  entirely  satisfactory  in  all  other  respects.  Generally  the 
curve  reaches  the  normal  only  after  the  seventh  day.  A  rise 
of  temperature  on  the  fourth  to  sixth  day  merely  indicates 
the  demarcation  of  the  scar,  and  the  good  general  condition 
of  the  patients  coincides  with  this  hypothesis.  The  tem- 
perature has  been  ascribed  by  some  to  faecal  retention,  and 
many  operators — for  instance,  Segond — have  the  bowels 
moved  by  a  glycerine  enema  on  the  evening  of  the  third 
day,  a  few  hours  after  taking  off  the  clamps.  Our  answer  to 
this  is  that  frequently  in  our  cases  the  temperature  comes 


i?o  THE  VAGINAL  RADICAL  OPERATION 

down  of  itself  before  the  evacuation  of  the  bowels.  We 
have  never  observed  a  threatening  rise  of  temperature  to 
104°  F.  (40°  C.),  with  disturbed  general  condition,  in  the  first 
week,  probably  because  in  our  vaginal  operations  we  do  not 
leave  cavities  and  spaces  in  which  retention  of  pus  or  secre- 
tions can  occur.  Therefore  all  the  manipulations  which 
others  have  recommended  and  practised  to  prevent  stasis  of 
the  secretion  and  '  surgical  fever '  in  the  first  few  days,  have 
no  interest  for  us.  Lafourcade  examines  such  cases  with  a 
Fergusson's  cylindrical  speculum,  and  removes  the  eschars 
under  visual  control,  and  in  case  of  the  escape  of  large  gan- 
grenous masses  he  employs  a  new  drainage  of  iodoform  gauze. 

For  our  part,  all  that  we  do  is  to  wait  twenty-four  hours 
after  the  removal  of  the  gauze,  generally  on  the  evening  of 
the  sixth  day,  and  then  begin  vaginal  irrigation  with  steril- 
ized lukewarm  water  once  or,  if  the  discharge  be  profuse, 
twice  daily  under  very  slight  pressure.  Although  we  have 
had  no  personal  experience  in  the  matter,  we  would  join  in 
the  warning  given  by  others  not  to  use  the  irrigation  too 
soon — that  is,  immediately  after  removing  the  gauze — and 
not  to  use  any  considerable  pressure  in  the  irrigation.  Severe 
local  peritoneal  irritation,  as  well  as  syncope  (Segond),  have 
been  observed  as  a  result  of  such  procedures. 

From  the  eighth  to  the  twelfth  day  the  discharge  is 
especially  profuse,  foul-smelling  and  dirty-coloured.  During 
this  time  the  discharge  and  the  irrigation  fluid  contain 
abundant  masses  of  necrotic  and  decomposing  tissue  shreds. 

About  the  fourteenth  to  sixteenth  day  with  the  majority  of 
the  patients,  the  irrigation  fluid  comes  away  clear,  and 
shortly  after  that,  the  last  traces  of  the  discharge  disappear. 
In  other  cases  there  may  be  a  catarrhal  secretion  for  four  to 
eight  weeks  more.  Where  the  operation  has  necessarily 
been  incomplete — that  is,  where  portions  of  pyosalpinx  or 
pelvic  abscesses  had  to  be  left  behind — the  discharge  will,  of 
course,  continue  until  these  secreting  fistulae  and  surfaces 
have  become  obliterated,  a  process  which  may  take  several 
months.  Still,  this  unpleasant  occurrence  is  but  a  slight 
memento  of  the  previous  objective  and  subjective  symptoms 
which  the  operation  has  relieved. 


THE  AFTER-TREATMENT  171 

Although  we  have  not  had  the  opportunity  of  getting  a 
direct  view  with  a  speculum  of  the  healing  process  taking 
place  in  the  vaginal  vault,  we  can  still  assert  that  its  union, 
i.e.,  the  closure  of  the  peritoneal  cavity  and  the  isolation  of 
the  vaginal  wound  from  the  latter,  must  be  completed  within 
a  very  few  days.  In  one  case,  the  digital  examination  of  a 
patient  on  the  seventh  day  showed  that  the  vagina  was  com- 
pletely shut  off  by  thin  soft  and  uneven  granulation  tissue 
with  a  slightly-indurated  margin.  When  the  convalescent 
patient  is  examined  prior  to  her  discharge — that  is,  about  the 
end  of  the  third  week  after  the  operation — one  finds  in  the 
dome-shaped  vagina  a  soft  linear  cicatrix  surrounded  by 
radiating  folds.  Later  it  becomes  firm,  and  is  often  hard  to 
differentiate.  Avoidance  of  sexual  intercourse  during  the  first 
eight  weeks  is  ordered,  for  the  protection  of  the  cicatrix. 

Instead  of  the  typical  convalescence  just  pictured,  it  occa- 
sionally happens  that  a  patient  at  the  end  of  the  first  week 
complains  of  temporary  or  continuous  pain  in  the  lower 
abdomen,  and  develops  fever.  We  have  had  these  un- 
desirable symptoms  in  a  few  cases  where  we  were  compelled 
to  leave  the  operation  incomplete,  allowing  suppurating 
pockets  or  spaces,  or  pieces  of  suppurating  tube,  to  remain. 
In  such  cases  we  abandoned  the  usual  expectant  after-treat- 
ment, and  tried  by  means  of  cautious  exploration  and  dilata- 
tion with  the  finger  to  make  a  free  outlet  in  the  vaginal 
vault  for  the  stagnant  discharges,  and  with  the  best  results. 
Secondary  drainage  or  tamponade  was  not  employed. 

At  another  time,  just  before  commencing  this  exploration, 
we  observed  a  spontaneous  evacuation  of  watery  sero-purulent 
fluid  in  such  a  profuse  quantity  as  to  almost  make  one  think 
of  a  sudden  vesical  incontinence.  As  we  afterwards  demon- 
strated, there  had  been  formed  in  the  vaginal  vault  a 
conglomerate  mass  of  peritoneal  cysts. 

In  another  case  the  convalescence  after  the  vaginal  radical 
operation  was  very  markedly  delayed.  Here,  following  a 
complicated  pelvic  abscess  in  a  virgo  intacta  (no  gonococci, 
no  tubercle  bacilli),  there  slowly  developed  a  board-like 
infiltration  of  the  preperitoneal  cellular  tissue,  which  pro- 
gressed for  weeks,  and  finally  extended  over  the  whole 


172  THE   VAGINAL  RADICAL  OPERATION 

abdominal  wall  up  to  the  ensiform  cartilage.  The  slightest 
touch  on  the  overlying  skin,  although  not  inflamed,  or  even 
reddened,  was  extremely  painful.  Repeated  incisions  and 
the  course  of  recovery  itself  showed  that  it  was  not  a  purulent 
or  phlegmonous  inflammation,  but  really  an  cedematous 
induration  and  gelatinous  infiltration  of  the  intensely 
reddened  and  swollen  preperitoneal  tissue.  The  process  sub- 
sided of  itself  after  three  months,  the  fever  disappeared,  and 
the  patient,  who  is  now  in  blooming  health,  presents  no  trace 
of  the  serious  and  extensive  affection  of  her  abdominal  wall. 

We  have  seen  two  other  rudimentary  examples  of  this 
apparently  as  yet  undescribed  process,  each  time  involving 
the  preperitoneal  tissue,  but  of  much  less  extent  and  gravity, 
and  of  shorter  duration. 

A  certain  amount  of  active  treatment  may  be  required  on 
account  of  secondary  haemorrhage,  which,  if  it  happens  at  all, 
occurs  generally  on  the  eleventh  to  thirteenth  day.  Once,  in  a 
previously  uneventful  recovery,  it  occurred  on  the  fourteenth 
day.  Curiously  enough,  the  severest  of  all  our  secondary 
haemorrhages  occurred  several  years  ago  in  a  patient  operated 
on  by  the  ligature  method.  It  is  as  yet  uncertain  whether 
these  haemorrhages  are  due  to  the  separation  of  large  sloughs 
or  dependent  on  the  menstrual  period,  or  both.  At  any  rate, 
the  simple  tamponade  is  sufficient  in  such  cases. 

After  the  tenth  day  we  allow  the  patient — who  up  to  this 
time  has  maintained  the  horizontal  posture — to  vary  her 
position  as  she  may  desire  :  to  lie  upon  the  side,  to  be  raised 
somewhat,  and  to  move  about  in  bed  very  cautiously.  In 
this  respect  we  have  often  been  anticipated  by  lively  patients, 
who,  when  the  chance  offered,  got  out  of  bed  as  early  as  the 
fifth  or  sixth  day,  for  instance,  to  be  able  to  urinate  more 
conveniently. 

On  the  sixteenth  to  eighteenth  day  the  patient  is  allowed 
out  of  bed,  and  there  is  nothing  to  hinder  her  discharge 
within  a  few  days  more.  It  is  advisable  to  have  the  vaginal 
irrigation  continued  once  daily  for  several  weeks  more  at  home. 

From  the  foregoing  regulations  for  the  after-treatment, 
the  chief  principle  during  this  time  may  be  considered  to  be 
the  greatest  possible  inactivity. 


EXPLANATION  OF  THE  ILLUSTRATIONS. 


THE  instruments  (Figs,  i  to  16)  are  drawn  according  to  nature.  The 
plates  19,  24,  25,  26,  27,  34,  36,  37,  41,  42,  43,  are  diagrammatic.  The 
process  adopted  for  the  others  was  as  follows :  During  the  various  stages 
of  the  operation  photographs  were  taken,  and  from  these,  large  drawings 
were  made,  which  were  reproduced  again  on  a  smaller  scale  for  the  plates. 

Figs.  39,  40,  44,  46,  47,  are  reproduced  exactly  according  to  the  photo- 
graphs of  the  preparations. 

The  following  are  the  clinical  and  anatomical  data  concerning  these 
plates  : 

FIG.  39. —  VAGINAL  RADICAL  OPERATION  WITH  TOTAL  MEDIAN 
SECTION  OF  THE  UTERUS. 

L.  K.,  nullipara,  37  years  old.  Ill  seven  years  ;  profuse  discharge  ; 
oppressive  pain  and  throbbing  in  both  sides  of  lower  abdomen,  radia- 
ting toward  the  thighs  ;  severe  pain  in  the  back.  Patient  comes  to  the 
clinic  because  she  is  so  greatly  reduced  by  her  illness  and  cannot  follow 
her  vocation. 

Operation,  June  14,  1894.  Pachypelviperitonitis  with  formation  of 
serous  cysts,  double  pachypyosalpinx.  Cystic  degeneration  of  both 
ovaries.  Large  intra-ligamentous  cyst  on  the  left  side.  Permanently 
cured. 

FIG.  40.  —  VAGINAL  RADICAL  OPERATION  WITH  TOTAL  MEDIAN 
SECTION  OF  THE  UTERUS. 

E.  B.,  primipara,  28  years  old.  One  child  seven  years  ago  ;  ill  ever  since. 
Suffers  from  severe  pain  in  lower  abdomen  ;  pressure  on  the  rectum  ; 
profuse  discharge.  Fever  for  a  long  time.  All  previous  medical  treat- 
ment unavailing.  Received  into  the  clinic  May  31,  1894. 

Operation,  June  6,  1894.  Double  pachypyosalpinx.  Bilateral  ovarian 
abscesses — single  on  the  right  side,  multiple  on  the  left.  Pachypelvi- 
peritonitis with  multiple  abscesses.  Permanent  cure. 

FIG.  44. — VAGINAL   RADICAL   OPERATION    WITH    IRREGULAR    MOR- 

CELLEMENT  OF  THE  SLIGHTLY-ENLARGED  UTERUS. 
M.  N.,  nullipara,  30  years  old.     Trouble  in  lower  abdomen  during  ihe 
last  four  years.     Only  temporarily  able  to  work,  then  confined  to  bed 


174  THE   VAGINAL  RADICAL  OPERATION 

again  two  to  five  weeks  with  pelvic  inflammation  ;  agonizing  pain,  espe- 
cially in  left  side,  with  fever.     Medical  treatment  without  result. 

Operation,  July  i,  1895.  Large  and  strikingly  soft  uterus.  Bilateral 
tubo-ovarian  abscesses.  Pachypelviperitonitic  adhesions  with  serous 
and  purulent  cysts.  Right  adnexa  morcellated.  Permanent  cure. 

FIG.  46. — VAGINAL  RADICAL  OPERATION  ACCORDING  TO  THE  MIXED 
METHOD  :  MEDIAN  SECTION  OF  THE  ANTERIOR 
CERVICAL  WALL— RESECTION  OF  THE  CERVIX  AFTER 
PREVENTIVE  H^EMOSTASIS  —  MEDIAN  TOTAL  SECTION 
OF  UTERUS. 

M.  K.,  nullipara,  29  years  old.  Contracted  gonorrhoea  nine  years  ago. 
One  abortion,  three  weeks'  hospital  treatment  therefor.  Since  then  has 
not  been  free  from  pain  in  lower  abdomen,  especially  on  the  right  side. 
Pain  radiating  towards  the  legs.  In  the  last  few  years  has  had  many 
attacks  of  pelvic  inflammation,  accompanied  by  fever,  and  confining  her 
for  weeks  in  bed,  sometimes  at  home,  sometimes  in  a  hospital.  During 
the  previous  three  weeks  was  again  in  bed  with  severe  pain  in  lower 
abdomen,  and  fever. 

Operation,  February  5,  1895.  Pachypelviperitonitic  adhesions  with 
intra-peritoneal  abscesses.  Pus-tube  on  both  sides,  cystic  degeneration 
of  both  ovaries.  Permanent  cure. 

FIG.  47. — ABDOMINO-VAGINAL  RADICAL  OPERATION  (SEE  P.  164)— 
RIGHT  ADNEXA  DELIVERED  BY  VENTRAL  LAPAROTOMY, 
THE  LEFT  TUBE  AND  OVARY,  TOGETHER  WITH  THE 
UTERUS,  REMOVED  PER  VAGINAM. 

J.  S.,  nullipara,  35  years  old.  Peritonitis  at  the  age  of  seventeen. 
Menstruation  during  the  next  year  exceedingly  painful.  During  the  last 
ten  years  is  said  to  have  had  constant  inflammation  of  the  womb,  with 
profuse  discharge  and  pain  in  the  back.  Has  undergone  ten  different 
'  cures  '  in  as  many  bath  resorts  and  springs.  Her  trouble  has  lately  been 
decided  by  a  very  eminent  authority  to  be  due  to  an  ovarian  tumour  with 
a  twisted  pedicle. 

After  unsuccessful  stay  in  a  number  of  sanatoriums  was  brought  to  the 
clinic. 

Operation,  November  15,  1894.  Gigantic  pyosalpinx  of  the  right  side; 
pachypyosalpingitis  of  the  left  side.  General  pelvic  peritonitis  with 
serous  cysts.  Permanent  cure. 


THE    END. 


Bailliere,  TirutaM  &>  Cox,  King  William  Sheet,  Stiand. 


University  of  California 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

405  Hilgard  Avenue,  Los  Angeles,  CA  90024-1388 

Return  this  material  to  the  library 

from  which  it  was  borrowed. 


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A     000356™" 


